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THE 

ABNER WELLBORN CALHOUN 

MEDICAL LIBRARY 

1923 




PRESENTED BY 



JDr. P. Jov, 3e^ 








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A TREATISE /*f#9; 



PATHOLOGICAL 
ANATOMY: 

BY G. ANDRAL, 



PROFESSOR TO THE FACULTY OF MEDICINE OF PARIS, MEMBER OF THE ROTAL 

ACADEMY OF MEDICINE, OF THE COUNCIL OF HEALTH, 

ETC. ETC. 



TRANSLATED FROM THE FRENCH, 
BY 

RICHARD TOWNSEND, A.B., M.D., M.R.I.A. 

AND 

WILLIAM WEST, A.M., M.D., M.R.I.A. 



VOL. II. 



EMORY UNIVERSITY 

JHE A. W. CALHOUN MEDISAL LIBRARY 
NEW YORK: 

SAMUEL WOOD & SONS, 261 PEARL-STREET. 
1832. 






PRINTED AT THE OFFICE 

OF THE 

MEDICO-CHIRURGICAL REVIEW, 

NO. 261 PEARL-STREET. 







TRANSLATOR'S PREFACE. 



The science of Morbid Anatomy has been cultivated in 
France with unprecedented zeal and success during the last 
thirty years, as may be abundantly proved by reference to the 
works of Corvisart, Bayle, Laennec, Broussais, Lallemand, 
Rostan, and Andral, which now form the text-books of patho- 
logical medicine all over Europe. Let me not, however, be 
understood as wishing to undervalue the labours of British 
pathologists, or to insinuate that they have not contributed their 
proportion to the general fund of pathological science. The 
names of Abercrombie, Armstrong, Baillie, Bright, Cooper, 
Farre, Hodgson, and Hooper, are of themselves sufficient to 
uphold the character of British pathology; but they are only a 
few of the many who in this country have distinguished them- 
selves by the success of their pathological investigations. Our 
Periodicals abound with excellent essays and monographs ; but 
since the days of Baillie we have had no regular treatise on the 
subject, with the exception of Dr. Craige's Elements of Gen- 
eral and Pathological Anatomy, which does not, in my opinion, 
supersede the necessity for a treatise on pathological anatomy, 
written by an original observer, and professing to give a faith- 
ful account of the present state of the science in that country 
where it has certainly been most successfully cultivated. Dr. 
Bailiie's treatise on Morbid Anatomy has been translated into 
the French, German, and Italian languages, and has deservedly 
enjoyed the highest reputation in this country since the period 
of its first publication. His descriptions of morbid appearances 
are excellent as far as they go; but, as a treatise on Morbid 



IV TRANSLATORS PREFACE. 

Anatomy, the work is totally inadequate to convey a just idea 
of the present improved state of the science.* To establish 
this assertion, I need only allude to the important additions 
that have been made since the time of its publication, to our 
knowledge of the morbid anatomy of the viscera of the three 
great cavities. The pathology of the abdominal viscera was 
never fully understood, nor its importance appreciated, until 
the attention of the Profession was directed to the subject by 
the writing's of Broussais ; the diseases of the cerebral organs 
have likewise received considerable elucidation from the re- 
searches of Lallemand and Rostan; and the name of Laennec 
is inseparably associated with the accurate knowledge we now 
possess of the different morbid alterations of the thoracic vis- 
cera: indeed by his successful labours, our knowledge of pul- 
monary disease has been brought to such a degree of precision, 
that medicine may now (at least in this department) fearlessly 
assert its claim to be ranked among the positive sciences. 

Besides the authors whose names I have just enumerated, 
and whose writings are all of later date than Baillie's, there 
are at the present day in Paris several physicians of talent and 
information, who literally devote their lives to the cultivation 
of this essential branch of medical science. The names of 
Louis, Bouillaud, Gendrin, and Reynaud, are familiar to every 
pathologist: as it was my good fortune to spend some time in 
the society of these gentlemen, I gladly avail myself of this op- 
portunity of bearing my testimony to their entheusiastic zeal 
for the interest of science, their indefatigable industry, accurate 
observation, and faithful and unexaggerated representation of 
the results of their investigations. The immense number of 



* Dr. Baillic states that he never saw but one instance of a hepatized lung, and 
that even that was in a preparation. It would be difficult to explain how he 
could have opened such a number of bodies without ever once finding a morbid 
alteration with which every tyro in morbid anatomy is now perfectly familiar, un- 
less we admit that diseased appearances are much better understood now than 
they were at the period when he wrote. 



TRANSLATOR S PREFACE. V 

facts collected by their united exertions forms a rich mine of 
pathological knowledge; but unfortunately these facts have 
hitherto been consigned to, or rather buried in, such a multi- 
tude of periodical publications, that they have been compara- 
tively unavailable to the interests of science. To collect these 
scattered facts, to add to them the results of his own observa- 
tions, and to arrange the whole into a system of pathological 
anatomy, forms the principal object of the present work. For 
this arduous task few persons could be better qualified than 
Professor Andral: placed by acclamation at the head of the 
Pathologists of the French school, he may be considered as the 
chosen organ of that body, and consequently as expressing the 
present state of the science in that country. He has himself 
made, perhaps, a greater number of post mortem examinations 
than any other pathologist in Europe ; accordingly, his work is 
unrivalled in the number of original observations it contains,* 
and I can assert from experience, having myself made within 
the last few years a very considerable number of dissections, 
that nothing can exceed the accuracy of his descriptions. But, 
M. Andral has not confined himself to the irksome task of 
merely enumerating the various physical alterations that take 
place in our organs ; he has likewise endeavoured to investigate 
the origin of these alterations, to explain the mechanism of 
their formation, and to trace their mutual relation and order of 
succession. In his investigation of these important points, he 
has laboured to restrict the influence of inflamation within ra- 
tional limits, and successfully combats the absurd doctrine, that 



* As an instance of the extensive scale on which his pathological investigations 
have been conducted, I may observe, that he introduces his description of the 
morbid alterations of the lymphatic vessels, by stating that he examined the 
thoracic duct in six hundred individuals. The number of positive facts collected 
by one who has enjoyed such extensive opportunities of observation are evidently 
worth all the theoretical reasonings of the literary compiler, who obtains his 
knowledge of morbid appearances from books, and compounds his elements of 
pathology in the study. 



vi translator's preface. 

every alteration of the living structure depends on an exalta- 
tion of its vital powers. He also examines the influence of 
these local alterations in the production of disease, and endeav- 
ours to point out how far the knowledge of these lesions may 
serve to aid us in determining its seat and nature, and to afford 
us certain data for the rational treatment of it. In short, he 
has attempted to combine pathology with morbid anatomy, 
and to deduce from their combination such conclusions as may 
serve to furnish us with more correct ideas of the nature of 
disease, and more fixed and rational principles for its treatment. 
In pursuing this investigation, he does not allow his judgment 
to be warped by any favourite theory. He admits the influ- 
ence of the solids in producing the phenomena of disease ; but 
he likewise accords considerable importance to the alterations 
of the fluids: he admits that local disease is capable of produc- 
ing general or constitutional disturbance; but he likewise main- 
tains that those general agents, the blood and nervous influence, 
may be primarily affected, and that in this way general disease 
may precede the existence of any local affection. These few 
instances may serve to shew that the work is written in the 
purest spirit of eclecticism ; indeed it appears a constant object 
of M. Andral's solicitude to reconcile the jarring interests of 
adverse doctrines, to select what is of real value from every 
theory, and thus to profit by them all, without wedding himself 
to any. The value of a treatise on Morbid Anatomy written 
on these principles by an author so eminently qualified for the 
task, is too evident to require demonstration. 

It now only remains to offer, in the name of my colleague 
and myself, a few remarks in our capacity of translators. Con- 
vinced that the first duty of a translator is to be faithful to his 
text, we have made this the constant rule of our practice ; the 
only instance in which we have ever even apparently deviated 
from it, being in the curtailment of a few cases which the 
author copied from other writers, and of an article on the pa- 
thology of the teeth, which was likewise extracted from the 
work of M. Serres. With these exceptions, we profess to give 
a full and fair translation of the original ; and as we are each 



TRANSLATORS PREFACE. Vll 

more especially accountable for the parts we have respectively 
translated, we wish to add, that the first volume was written 
by Dr. Townsend, with the exception of the Preface, and the 
last 118 pages, and that in this volume, all the articles were 
translated by Dr. West, except those on the morbid alterations 
of the circulatory and respiratory apparatuses, from page 182 
to page 354 inclusive, which were translated by Dr. Townsend. 

R. T. 

Merrion-square, 
Nov. 19th, 1830 



CONTENTS 

OF THE SECOND VOLUME. 



PART SECOND. 

Special Pathological Anatomy. 



DIGESTIVE APPARATUS. 
Digestive Apparatus . 



CHAPTER II. 

Of the alimentary canal considered in a state of disease 
Art. I. Lesions of Circulation 

§ I. Hyperaemia of the alimentary canal 
§ II. Anaemia of the alimentary canal 
Art. II. Lesions of Nutrition 

§ I. Hypertrophy of the alimentary canal . 

A. Hypertrophy of the mucous membrane 

B. Hypertrophy of the tissues subjacent to the i 

cous membrane .... 
§11. Atrophy of the alimentary canal 
§ III. Softening of the alimentary canal 



Page. 

3 



SECTION I. 

Diseases of the portion of the alimentary canal below the 

diaphragm 4 

CHAPTER I. 

Of the alimentary canal in the healthy state ... 5 



26 
27 
ib. 
34 
35 
ib. 
ib. 

43 

54 
56 



CONTENTS. IX 

Page. 

I. Of the softening of the mucous membrane alone 56 
II. Softening of all the layers of the gastrointes- 
tinal parietes ..... 60 
§ IV. Ulceration of the alimentary canal . . 66 
§ V. Perforations of the alimentary canal . . 75 
§ VI. Changes of capacity in the alimentary canal, sub- 
sequently to various lesions of nutrition . S4 
§ VII. Congenital lesions of nutrition ... 93 

A. Faults of configuration .... 95 

B. Faults of dimension ..... 96 

C. Faults of situation ..... 99 

D. Imperforation of the natural apertures, |and pre- 

ternatural communication between the in- 
testines . . . . . .102 

Art. III. Lesions of Secretion . . . .103 

§ I. Morbid secretions in the mucous membrane ib. 

A. Natural secretions increased in quantity . 104 

B. New secretions ..... 107 
§ II. Morbid secretions beneath the mucous membrane 121 

Art. IV. Entozoa of the alimentary canal . . . 128 

I. Ascaris Lumbricoides . . . .129 

II. Trichocephalus . . . . . .131 

III. Oxyuris . . . . . . 132 

IV. Taenia ib. 

Art. V. State of the Alimentary canal in the different 

cases where its functions are deranged . 134 
§ I. State of the alimentary canal in its various 

functional derangements . . .135 

§ II. State of the alimentary canal in fever . . 149 

§ HI. State of the alimentary canal in the diseases of 

the various organs . . . .155 

SECTION II. 

Diseases of the portion of the alimentary canal above the dia- 
phragm 161 

CHAPTER I. 

Accidental lesions of that portion of the alimentary canal sit- 
uated above the diaphragm 163 



Paga. 

Art. I. Lesions of the mouth and pharynx . . 163 

Art. II. Lesions of the oesophagus .... 170 

CHAPTER II. 

Congenital lesions of the portion of the alimentary canal situated 

above the diaphragm 173 



CIRCULATORY APPARATUS. 

SECTION I. 

Diseases of the heart 182 

CHAPTER I. 

Lesions of Circulation 183 

CHAPTER II. 

Lesions of Nutrition 186 

Art I. Lesions of Nutrition that impede the free circula- 
tion of the blood through the heart . . 187 

A. Obstacles seated in the orifices of the heart . 193 

B. Obstacles in the arteries . . . .194 

C. Obstacles in the capillaries .... ib. 
Art. II. Lesions of Nutrition that do not.alter the dimen- 
sions of the heart . . . . .197 

§1. -Induration . 198 

§ II. Softening ....... ib. 

§ III. Solutions of continuity 200 

CHAPTER III. 

Congenital Malformations 203 

§ I. Absence of the heart, or acardia . . . 204 
§ II. Imperfect or irregular developement of the heart, 

or atelocardia 205 



Page. 

§ III. Excessive developement of the heart . . 206 
§ IV. Alterations in the line of direction of the heart . 207 
§ V. Displacement of the heart. Ectopia cordis . ib. 

CHAPTER IV. 

Lesions of Secretion 208 

Art. I. Lesions of the fatty exhalation of the heart . 209 
Art. II. Lesions of the perspirable exhalation of the heart 210 
§ I. Lesions of the perspirable exhalation in the pa- 
renchyma of the heart .... ib. 
§ II. Lesions of the perspirable exhalation in the cavities 

of the heart 217 

chapter v. 
Lesions of the blood contained in the cavities of the heart 217 

CHAPTER VI. 

Lesions of the innervation of the heart .... 223 

SECTION II. 
Diseases of the arteries. ..... 227 

CHAPTER I. 

Lesions of Circulation fa 

CHAPTER II. 



Lesions of Nutrition . . . "" , 

I. Dilatation of the arteries 

II. Narrowing of the arteries .... 237 

III. Obliteration of the arteries .... 239 



. 231 
. 233 



CHAPTER III. 



Congenital lesions of nutrition 241 

1* 



Xll CONTENTS. 

Page. 
CHAPTER IV. 

Lesions of Secretion 242 

CHAPTER V. 

Lesions of the innervation of the arteries . . • 248 

SECTION III. 

Diseases of the veins . . . . . . • 250 

CHAPTER I. 

Lesions of Circulation . 251 

CHAPTER II. 

Lesions of Nutrition ....... 252 

CHAPTER III. 

Lesions of Secretion ....... 259 

SECTION IV. 
Diseases of the spleen 265 

CHAPTER I. 

Diseases of the spleen which have their seat in the matter con- 
tained in its cells 267 



Art. I. Alterations in the consistence of the spleen 
Art. II. Alterations of size .... 

Art. III. Alterations of colour .... 
Art. IV. New productions .... 



268 
ib. 

270 
ib. 



CHAPTER II. 

Diseases of the spleen affecting its fibrous tissue . . 273 



CONTENTS. Xlll 

Page. 
CHAPTER III. 

Nature and causes of the alterations of the spleen . . 274 

SECTION V. 

Diseases of the lymphatic system 275 

CHAPTER I. 

Diseases of the lymphatic vessels .... 276 

CHAPTER II. 

Alterations of the lymph 277 

CHAPTER III. 

Diseases of the lymphatic ganglions .... 280 



RESPIRATORY APPARATUS. 
Respiratory Apparatus 286 

SECTION I. 

Diseases of the air tubes 290 

CHAPTER I. 

Lesions of the mucous membrane i& # 

Art. I. Lesions of Circulation . . . .291 

Art. II. Lesions of Nutrition 293 

Art. III. Lesions of Secretion 299 

CHAPTER II. 

Lesions of the tissues subjacent to the mucous membrane . 307 



XIV CONTENTS. 

Page. 
CHAPTER III. 

Alterations in the dimensions of the air tubes . . .311 

SECTION II. 

Diseases of the parenchyma of the lungs . . . 305 

CHAPTER I. 

Lesions of Circulation '316 

Art. I. Hyperemia of the lung . . . ib. 
Art. II. Anaemia of the lung 322 

CHAPTER II. 

Lesions of Nutrition 323 

Art. I. Hypertroyhy of the lung .... 324 
Art. II. Atrophy of the lung 329 

CHAPTER III. 

Lesions of Secretion ....... 333 

§ I. Secretion of pus 335 

§11. Secretion of tubercle 338 

CHAPTER IV. 

Lesions of the innervation of the lungs .... 350 

SECTION III. 
The thyroid gland . . 353 



SECRETORY APPARATUSES. 
Secretory Apparatuses 355 



SECTION I. 

Diseases of the apparatuses specially adapted to the secretion 
of the perspiratory fluid. (The cellular tissue and serous 

membranes.) 357 

CHAPTER I. 

Lesions of the secreting tissue 358 

CHAPTER II. 

Lesions of the fluid secreted by the serous and cellular mem- 
branes . . . . . . . . .361 

SECTION II. 

Diseases of the glandular organs of secretion . . . 365 

CHAPTER I. 

Diseases of the liver and its appendages .... 366 

Art. I. Diseases of the parenchyma of the liver . ib. 

§ I. Lesions of Circulation of the liver . . 368 

§ II. Lesions of Nutrition of the liver . . . 369 

§ III. Lesions of Secretion of the liver . . . 372 

Art. II. Diseases of the biliary ducts . . . 377 

Art. III. Alterations of the bile 379 

CHAPTER II. 

Diseases of the urinary apparatus .... 383 

Art. I. Diseases of the kidneys .... ib. 

§ I. Lesions of Circulation ib. 

§ II. Lesions of Nutrition ..... 385 

§ III. Lesions of Secretion ..... 390 

Art. II. Diseases of the excretory passages of the urine 393 

§ I. Diseases of the calices, pelvis, and ureters . ib. 

§ II. Diseases of the bladder .... 395 

A. Lesions of Circulation . . . . . ib. 



Page. 

B. Lesions of Nutrition ..... 396 

C. Lesions of Secretion 400 

§111. Diseases of the urethra . . . • 400 

§ IV. Alterations of the urine . . • • • 402 

A. Alteration of the urine from a change in the propor- 

tion of its constituents .... ib. 

B. Alteration of the urine by the addition of new prin- 

ciples that are found in the blood . . 404 

C. Alteration of the urine by the addition of new prin- 

ciples that are not to be found in the blood . 405 



APPARATUS OF GENERATION. 
Apparatus of Generation 408 

SECTION I. 

Diseases of the male genital organs ib. 

SECTION II. 

Diseases of the genital organs of the female . . . 412 

CHAPTER I. 

Diseases of the uterus ib. 

CHAPTER II. 

Diseases of the fallopian tubes 424 

CHAPTER III. 

Diseases of the ovaries 426 

CHAPTER IV. 

Diseases of the breasts 432 



CONTENTS. XV11 

Page. 
CHAPTER V. 

Diseases of the foetus and its appendages . . . 437 



APPARATUS OF INNERVATION. 



. 443 



Apparatus of Innervation .... 

SECTION I. 

Diseases of the brain and spinal cord .... 445 

CHAPTER I. 

Lesions of Circulation . . ..... t'6. 

Art. I. Hyperemia ...... ib. 

§ I. Hypergemia without effusion of blood . . ib. 

§ II. Hypersemia with effusion of blood . .451 

Art. II. Anaemia 456 

CHAPTER II. 

Lesions of Nutrition ....... 457 

Art. I. Hypertrophy of the nervous centres . . 458 

Art. II. Atrophy of the nervous centres . . . 461 

Art. III. Ramollissement of the nervous centres . . 465 

Art. IV. Induration of the nervous centres . . . 469 

Art. V. Ulceration of the nervous centres . . . 472 

CHAPTER III. 

Lesions of Secretion 473 

Art. I. Exhalation of serum in or around the nervous 

centres 474 



Art. II. Secretion of pus .... 
Art. III. Secretion of tubercle 
Art. IV. Scirrhous and encephaloid productions 
Art. V. Fatty productions 

1** 



482 

485 

487 

ib. 



Page. 

Art. VI. Fibrous, cartilaginous, and osseous productions 488 

Art. VIL Entozoa 489 

SECTION II. 

Diseases of the cerebral and spinal nerves . . 490 

CHAPTER I. 

Lesions of Circulation 491 

CHAPTER II. 

Lesions of Nutrition 496 

Art. I. Hypertrophy ib. 

Art. II. Atrophy . . 498 

CHAPTER III. 

Lesions of Secretion . . . , . . 502 

SECTION III. 

Diseases of the sympathetic nerve . . . . . 505 



PART II. 



SPECIAL PATHOLOGICAL ANATOMY. 



Vol. II. 



A TREATISE 

ON 

MORBID ANATOMY 

AND 

PATHOLOGY. 



PART SECOND. 

SPECIAL PATHOLOGICAL ANATOMY. 



It is my purpose, in this second part, to describe the morbid 
states of the several apparatuses, considering the lesions they 
may present particularly with regard to the pathology of the 
interior. 



DIGESTIVE APPARATUS. 



This apparatus is composed of two distinct parts ; the one 
situated below the diaphragm, and the other above it. I shall 
devote a separate section to the diseases of each part. 



DISEASES OF THE ALIMENTARY CANAL. 



SECTION 



DISEASES OF THE PORTION OF THE ALIMENTARY CANAL 
BELOW THE DIAPHRAGM. 

Four grand periods may be distinguished in the history of 
medicine, as regards the manner in which the diseases of the 
alimentary canal have been considered with respect to their 
nature. In the first, and longest of all, which commenced at 
the time of Hippocrates, and terminated almost in our own, 
pathological anatomy was either totally neglected, or else 
badly applied ; and the nomologists, grouping symptoms ar- 
tificially together, made so many distinct diseases of them ; 
so that each morbid phenomenon was considered as a sep- 
arate affection. In the second period, comprising particularly 
the works of Bayle and Laennec, pathological anatomy ban- 
ished those classifications of diseases by symptoms : thus, from 
that out, the history of vomiting, or of dyspepsia, for instance, 
was no longer separated from that of the lesions that produce 
them. In like manner, however, as distinct diseases had for a 
long time been composed of symptoms artificially grouped, so 
now, Laennec and his disciples composed in their turn artificial 
groupes in pathological anatomy, if I may so express myself. 
Being struck chiefly with the difference of form and appear- 
ance of certain lesions, they did not perceive that these differ- 
ent lesions were often the termination of the same morbid 
state, which, many times at least, should be put in the first 
rank, as being the source and connecting tie of them all. Con- 
sidering these lesions only, they were naturally led to regard 
as essentially different with respect to their causes, many 



BELOW THE DIAPHRAGM. 5 

which differed only in their forms. Thus, in their nosological 
scale, they placed cancer of the stomach and chronic gastritis 
at a great distance from each other. The third period dates 
its existence from the doctrines of M. Broussais, who main- 
tained that certain lesions of the alimentary canal most dis- 
similar in appearance had yet the same origin ; and that a slight 
red or brown thickening of the mucous membrane of the stom- 
ach, and a vast ulcer of the same membrane, or a scirrhous 
induration of the subjacent nervous tunic, should equally be 
referred to an augmentation of the organic action of the tissues : 
but, I would ask, does that hold good in all cases ? I think not; 
and a fourth period has already commenced, in which, com- 
bining the exclusive theories of the two preceding, while we 
acknowledge with Broussais that irritation is the common tie 
which unites many gastro-intestinal lesions, though until his 
time it had remained unsuspected, we yet are beginning to be 
convinced, 1. that irritation does not constitute the whole 
phenomenon ; 2. that sometimes it is its source, and some- 
times only one of its elements ; 3. that if we attempt to ac- 
count by irritation solely for the special nature of morbid pro- 
ductions, we must necessarily admit that it diners much less 
in its degrees than in its modes ; 4. and lastly, that in many 
cases, even the existence of irritation is not demonstrated 



CHAPTER I. 



Of the Alimentary Canal in the healthy State. 

There has been hitherto so little agreement on the subject 
of the natural appearance of the stomach and intestines, that I 
consider it indispensable to determine accurately what is the 
anatomical condition of the alimentary canal in the healthy 
state. Perhaps one circumstance which has long been an ob- 



6 DISEASES OF THE ALIMENTARY CANAL 

stacle to the ascertainment of this point, is the great frequency 
of gastro-intestinal alterations. As there are very few sub- 
jects in which some of these are not met with, anatomists had 
become accustomed to consider them as belonging to the nat- 
ural state of the parts ; and they seemed the more warranted 
in doing so, as, until very lately, the symptoms produced by 
these alterations were either totally unknown or ill under- 
stood. 

If we examine the internal surface of the stomach or intes- 
tines in a living animal, that is not struggling, and whose circu- 
lation is not disturbed, we find it of a red tint somewhat deeper 
than that of the mucous membrane of the cheek in a healthy 
man. If we examine the same animal after death, we find that 
this red tint has disappeared, and that the surface is now uni- 
formly pale, or, at most, very slightly rose-coloured. In order 
that the experiment should afford these results, the animal must 
be deprived of life in such a manner as not to lose too much 
blood, on the one hand, as the natural paleness of the intestine 
would then be increased; or to die in a state of asphyxia, on 
the other, as the mucous membrane would then be mechanic- 
ally injected ; which, though not a morbid, would yet not be 
the natural state. 

I think we may conclude from this experiment that, after 
death, the mucous membrane of the stomach and intestines 
tends to lose its colour like the skin. 

There have been frequent opportunities of examining bodies 
in cases of accidental death, where the individual was appa- 
rently in the enjoyment of perfect health a few mintutes pre- 
viously. In most of these cases, also, the alimentary canal has 
been found free from any red tint. 

Sometimes, however, different degrees of injection have 
been observed on the internal surface of the stomach or intes- 
tines, as well in animals supposed to be sound, that were 
sacrificed to physiological experiments, as in men in cases of 
accidental death. To this it may be answered in the first place, 
that if the alimentary canal had been found oftener without 
any redness, under the same circumstances, it is very probable 
that in the cases where the redness was observed, it arose from 



BELOW THE DIAPHRAGM. * 

disease. But, besides, the appearance of the parts that were 
found injected should have been described with more care and 
precision ; and a detailed account should have been given of 
the kind of death the animals suffered, and of the space of time 
that had elapsed between the accident and death in the other 
cases. 

There are, in fact, certain circumstances under the influence 
of which the alimentary canal though free from disease, may 
yet present various degrees of red coloration in the dead body. 
Of these circumstances, some may have operated a certain 
period before death, others only during the last moments, and 
lastly, others either soon or at some length of time after the 
cessation of life. 

Of the causes which operate before death, some are physi- 
ological and others pathological. Thus, it is an undoubted fact, 
that, during the process of chymification, the internal surface of 
the stomach acquires a considerable degree of redness; as well 
as that the small intestine does the same while the separation 
of the chyle is taking place in it: any one may convince himself 
of the truth of these assertions by examining living animals. 
But, beside, it has been ascertained by observation that this red- 
ness that is produced by digestion continues after death ; so that 
on opening the body of any individual that has died while chym- 
ification or chylification was going on within him, we shall find 
those portions of the alimentary canal in which the process 
had been taking place of an unusually high colour. 

The pathological causes are all such as act by presenting 
some obstacle to the free return of the venous blood from the 
gastro-intestinal parietes to the right cavities of the heart. 
There happens then to the mucous membrane of the alimentary 
canal what happens to the skin in persons who die of asphyxia : 
in such cases we observe the cutaneous surface long before 
death acquiring a constantly increasing colour from the venous 
blood; now, what takes place in the skin must also take place 
in the intestine. We may assure ourselves directly of this by 
examining a coil of intestine in an animal who is slowly suffo- 
cating, when we shall find that, as the respiration becomes 
more difficult, the coil assumes a more intense and uniform red 



8 DISEASES OF THE ALIMENTARY CANAL 

hue. Lastly, if, as Boerhaave did long ago, we prevent by a 
ligature the circulation of the blood in the trunk of the vena 
portae, we shall observe the whole of the internal surface of the 
intestines assuming a fine red tinge, which is compared by 
Morgagni to the colour of cochineal; and sometimes, even, 
blood transudes through the parietes of the distended vessels, 
and fills the intestine. These facts being known, it is only 
drawing the conclusion from them to establish that, every time 
the blood cannot return freely from the capillaries of the in- 
testinal mucous membrane to the venous trunks, that mem- 
brane will continue coloured after death. Hence arise the 
various shades it presents in cases of strangulated hernias, for 
instance, or of obstructions of the liver, of tumours situated on 
the course of the principal divisions of the vena portae, of ob- 
literation of the vein itself by old coagula, and, lastly, of organic 
affections of the heart. If, however, there was but little blood 
in the body, whether through defect or sanguification, or in 
consequence of recent copious bleedings, a considerable obsta- 
cle to the venous circulation would produce a less intense 
coloration of the alimentary canal, than that which would arise 
from a slighter obstacle existing in a person whose vessels con- 
tained a great deal of blood a short time before death. 

The red coloration of the gastro-intestinal parietes in conse- 
quence of some mechanical obstacle to the venous circulation, 
presents various degrees of intensity. In the lowest of these, 
the submucous cellular tissue alone is coloured, but not in its 
capillary network ; it is traversed in various directions by blu- 
ish veins of pretty large calibre, which cease to be injected on 
arriving at the mucous membrane, while their other extremi- 
ties are continuous with the mesenteric veins, which are them- 
selves equally gorged with blood. In a higher degree of injec- 
tion, depending quite as much on mechanical causes as the 
preceding, the mucous membrane itself begins to assume a 
tinge, and, according to the size, number, and relative situation 
of the injected vessels perceptible to the naked eye, it exhibits 
either simple branches separated by large colourless intervals, 
or ramifications of greater or less extent, produced by the in- 
jection of the smaller vessels, or, lastly, a redness considerable 



BELOW THE DIAPHRAGM. V 

enough to produce a complete opacity of the parietes where- 
ever it exists. According as these various shades of colouring 
are extended or circumscribed, the result will be either a dif- 
fused redness of the intestine without any precise limits, or else 
streaks, stripes, patches, or mere points. In fact, there is not 
one of these appearances that may not be produced by a simple 
injection from a hyperasmia either mechanical or passive ; and 
he would be strangely mistaken who should imagine that the 
dotted redness, for instance, more necessarily announces an 
active hypersemia, than does the simple congestion of some of 
the submucous veins. In these different cases, on attentively 
examining the injected parts, we may perceive that the inject- 
ed vessels are directly continuous with the great veins subja- 
cent to the mucous membrane, just as these latter are continu- 
ous with the mesenteric. 

If the obstacle to the return of the blood from the intestines 
to the heart is still more considerable, or if, what comes to the 
same thing, the obstacle not being increased, there is an in- 
crease of blood in the vessels, that fluid escapes from them, 
and becomes effused, either into the submucous cellular tissue, 
where it forms ecchymoses, or into the cavity of the intestine 
itself, where it communicates a reddish tint to the bile, mucus, 
or other matters that happen to be contained in it. The fa- 
cility with which a liquid or gaseous injection may be made to 
penetrate into the intestinal cavity when driven into the mesen- 
teric veins from the trunks towards their branches, explains 
how, under the influence of a considerable congestion of the 
same veins, a part of the blood contained must have a tenden- 
cy to escape into the interior of the alimentary canal. 

Thus, on summing up all that we have learned both from 
simple physiological reasoning, experiments on animals, and 
the examination of dead bodies, we are led to conclude that 
the gastro-intestinal mucous membrane may be indifferently 
white or red, without either of these colours necessarily indi- 
cating that the membrane had been in a morbid state ; it is 
either white or red, of various shades, according as there has 
existed before death some one of the conditions, mechanical, 
organic, or vital, which we have endeavoured to explain. Now, 
Vol. II. 3 



10 DISEASES OF THE ALIMENTARY CANAL 

as those which produce the red coloration exist the most fre- 
quently, it follows that, in the dead body, we should more fre- 
quently find the alimentary canal injected than colourless. But 
that is not all : after life has ceased, new causes arise which 
tend to produce new modifications in the colour of the intes- 
tines, and to inject some parts of it much more strongly than 
they were at the moment of death. The causes of redness 
produced after death may be reduced to two principal ones : 
one, the weight of the blood, and the other, its transudation 
through the parietes of its vessels. 

The first of these causes begins to act immediately after 
death. The reality of its existence has been fully proved by 
MM. Trosseau and Rigot, in a memoir abounding in interesting 
facts and ingenious views. 

If we fix to a nail the two united extremities of a coil of in- 
testine supplied by veins gorged with blood, we shall perceive, 
after a short time, the most dependent part of the coil, consti- 
tuting the middle of the convexity of the curve thus formed, as- 
suming a very marked red Colour, while the less dependent 
parts become paler and paler, and the mesenteric veins get rid 
of the great quantity of blood they contained in the vessels of 
the intestinal parietes, provided it be liquid, changes its place 
after death, and tends to accumulate in those parts of them 
where it is attracted by the laws of gravitation. Now, if this 
takes place in a coil of intestine separated from the body, it 
must occur equally in the interior of the abdomen, where the 
same physical law must also act. To settle this point, MM. 
Trousseau and Rigot began by placing the bodies in such a 
situation that the influence of gravitation should be beyond all 
doubt. Thus, upon leaving in a vertical position for several 
hours the bodies of some dogs that had been previously 
strangled, they ascertained that, in those parts of the intes- 
tines that had been thereby rendered very dependent, the mu- 
cous membrane was of a lively red, its villi were strongly in- 
jected, blood was effused into the interior, where it tinged the 
bile and the mucus, and there were ecchymoses in the submu- 
cous cellular tissue. In other dogs which had likewise been 
strangled, but were then placed on the belly, tbe portions of 



BELOW THE DIAPHRAGM. 11 

intestines which were most dependent in this new position 
were most highly coloured. In horses killed by cutting the 
spinal cord, and placed afterwards on their back, but yet so 
that the bodies were sometimes more inclined to the right, and 
sometimes to the left, they found in like manner that the coils 
which were the most strongly injected, nay, the only ones 
which were so at all, were those in which the law of gravita- 
tion should have exerted its greatest influence in these various 
positions. They also remarked, in the course of their experi- 
ments, that those which were shrunk and contracted, so that 
their vessels were doubled on themselves, were not injected, 
although placed in a dependent position. In the horse, on the 
contrary, the superior portions of intestine, which were remark- 
able for their great diameter, were found to have their under 
side injected frequently enough. If, on opening the body of 
an animal which has just died, we fix certain portions of the 
alimentary canal in a dependent position, and examine them 
again some time afterwards, we find them injected, though 
they were not so at the time of the first examination. M. 
Trousseau tells us he opened, six hours after death, the body 
of a man who died of a typhus fever : on examining some de- 
pendent parts of the ileum they appeared to have a slight red 
tint, while the superior parts were, on the contrary colourless: 
the intestines were then replaced. Next morning, on examin- 
ing those dependent coils which had not been opened the pre- 
ceding day, as well as those which had been partially so, he 
found them full of mucus coloured by the blood, which had im- 
parted a violet tint to their internal membrane. These facts 
fully confirm my own observations. For this long time back, 
while examining the bodies opened at La Charite, I have con- 
stantly been struck with the circumstance that those coils of 
the small intestine which are more dependent than the rest, 
those, for instance, which are sometimes found sunk in the hol- 
low of the pelvis, are also more strongly injected. It becomes 
a question whether this coloration from hypostasis can occur in 
the small intestine only; it certainly can occur with more fa- 
cility there than elsewhere, by reason of its disposition, and of 
that of the vessels distributed to it. I am, however, strongly 



12 DISEASES OP THE ALIMENTARY CANAL. 

inclined to think that, in certain cases, the redness observed on 
the great extremity of the stomach, and on its whole posterior 
surface in general, (that being inferior in the subject,) results 
in like manner from this accumulation of blood by hypostasis. 
I am the more disposed to this opinion, from finding it men- 
tioned in my notes that, in a case where a body had been laid 
upon the abdomen a short time after death, preparatorily to 
opening the spinal canal, and remained several hours in that 
position, the anterior part of the stomach was injected, and 
dotted with red, while the posterior part was pale. At the 
time I imagined it to have been caused by gastritis ; but I 
should not be apt to think so now. 

The redness of the intestinal parietes that is produced, 
wholly after death, by injection from hypostasis, the reality of 
which I have just now proved, presents various degrees or 
shades, like the redness from congestion, either mechanical or 
passive, that had been previously under consideration. Thus, 
we may find the villi highly coloured, and even blood effused 
into the interior of the intestinal canal. This, however, very 
seldom happens, except in experiments on animals that are 
strangled, and kept in the vertical position for several hours after 
death. In such cases, in fact, every thing is most favorably 
disposed for the blood's being drawn in the greatest possible 
quantity to where it is attracted by the law of gravitation. 
Nothing similar has ever been observed in the horses killed by 
pithing, or by knocking on the head ; and, in the human subject, 
the determination of the blood towards the most dependent 
parts of the alimentary canal, most commonly produces in it 
only an injection more or less strong of the mucous membrane 
or of the subjacent cellular tissue ; which may produce either a 
diffused tint with an appearance of ramifications, or circumscri- 
bed blushes in form of points, spots, streaks, &c. 

Injection from hypostasis begins to take place immediately 
after death, acquires its highest degree at the end of some 
hours, and ceases to be continued as soon as the blood, having 
cooled, begins to coagulate. Hence it follows that in subjects 
whose temperature is long kept up either naturally or artificially, 
and in which the blood continues fluid, the injection of the in- 



BELOW THE DIAPHRAGM. 13 

testines from hypostasis will be much more decided than under 
the opposite circumstances. It will also be more considerable 
when, after acute diseases, a great deal of blood still remains in 
the system ; and when, in consequence of a slow death, or of 
obstacles to the circulation, the intestinal veins were gorged 
with blood at the moment of the cessation of life. 

As soon as a certain space of time has elapsed after death, 
a new cause of coloration begins to act : as soon as putrefac- 
tion begins to seize upon the body, the blood contained in the 
vessels, both large and small, of the gastro-intestinal parietes 
exudes through the membranes of those vessels, and is effused 
in variable quantities into the surrounding tissues, especially 
into the submucous cellular tissue. On this extravasation of 
the blood depend, for instance, the red spots almost always ob- 
served in the stomach along the veins of its great extremity, 
when the body is opened more than six and thirty or forty 
hours after death. These spots thus assembled along the 
course of the vessels are sometimes isolated, and sometimes 
grouped together and running into one another ; and in this 
manner mark the surface of the stomach with streaks and bands 
of various figures. If after having observed the stomach in 
this condition, we leave it, and examine it again at a later period, 
we find that the redness has increased, and that, moreover, it 
appears in a new form : it no longer exists solely along the ves- 
sels, but the whole surface of the stomach presents a tinge 
which has a constantly increasing tendency to become uniform ; 
and a period at last arrives, when all the membranes, having 
become soaked with blood, are equally red ; they may then 
have a tint almost similar to that which we observe on the in- 
ternal surface of the arteries when stained by the contained 
blood. This kind of redness formed after death cannot, how- 
ever, proceed to such a high degree, unless in cases where a 
certain quantity of blood existed in the vessels of the stomach 
at the moment of death ; and as, from the effects of gravita- 
tion, that fluid accumulates towards the great extremity of the 
stomach in particular, it follows that it is there we should see 
the redness from transudation most strongly marked. It would 
be useless to attempt to -fix precisely the period at which this 



14 DISEASES OF THE ALIMENTARY CANAL 

transudation should commence ; for, in order to do that, we 
should fix precisely the period at which putrefaction commen- 
ces. Now, that period is very variable, as it depends, I. on 
certain conditions relative to the body itself; such as the kind 
of death, the nature of the disease that produced it, &c. ; and, 
2. on certain external circumstances, especially on the ther- 
mometrical and hygrometrical states of the place in which the 
body is. Accordingly, when, in summer time, we open bodies 
that have been kept, since death, in warm beds, and in rooms 
of a temperature at least as high as that of the external air, it is 
usual to find, so soon as after four and twenty hours, very evi- 
dent marks of transudation in the alimentary canal : in such 
cases, for instance, I have often found all the membranes of 
the great extremity of the stomach of a uniform red tinge. 
Under similar circumstances, the colouring matter of the blood 
may likewise transude, spread over the internal surface of the 
canal, and mix with the fluids contained. I have ascertained 
this to be the case in most of the bodies I had occasion to ex- 
amine in the very warm summers of 1825 and 1826. 

The spleen, also, may suffer some blood to transude through 
its parietes ; and this may then soak into the adjacent portion 
of the stomach and impart its colour to it. This kind of color- 
ation, however, is less frequent than that which results from 
the transudation of the blood through the parietes of the gastric 
vessels. One of the circumstances that must have some effect 
in producing a variation in this cause, is, undoubtedly, the dif- 
ference of the states in which the blood may be that is con- 
tained in the spleen ; as the more liquid it is, the more readily 
must it soak through the enveloping membrane of that organ. 

Lastly, even at the time we are engaged in examining the 
internal surface of the alimentary canal in the dead body, we 
may often produce in its mucous membrane, by scraping it 
with the back of a scalpel, a redness which not only did not 
exist during life, but which was not even apparent before the 
scraping. The effect of this operation is to squeeze into the 
finest vessels of the mucous membrane, and into a single point 
in those, the blood which, being before that dispersed in the 
mass of the surrounding vessels, was much less apparent : ex- 



BELOW THE DIAPHRAGM. 15 

travasation, even, may be produced in this manner. It is to be 
observed that this artificial redness can be produced only when 
there previously exists a certain quantity of blood in the mu- 
cous membrane or below it : it most commonly assumes a 
dotted form. 

When we plunge a bladder filled with blood into different 
gases, the blood becomes singularly altered in colour.. It fol- 
lows that whenever these same gases are developed in the in- 
testines, they must also affect the blood similarly through the 
parietes of its vessels. In some cases that may occur a very 
short time after death ; but these gases being in general pro- 
duced only by putrefaction, it is not until that process is toler- 
ably advanced, that the gases resulting from it can modify the 
colour of the blood, and change into brown or green, &c, the 
red tint which existed during life, or was formed after death by 
hypostasis or imbibition. 

The bile that is found in the alimentary canal after death in 
more or less considerable quantities, most commonly lines its 
internal surface without tinging it ; but sometimes the yellow 
matter soaks into the mucous membrane, combines intimately 
with it, and produces a yellow tinge which cannot be removed 
by washing. This may exist only in isolated spots, or affect a 
great extent uniformly ; and it is often found very strongly 
marked in the stomach, where bile does not naturally occur. 
More than once, for instance, I have found the whole internal 
surface of the right half of that viscus stained uniformly of a 
fine ochre colour. I am inclined to think that this may be 
owing to the presence of an acid in the stomach, which must 
have a tendency to separate from the bile its yellow matter, 
which in this free state is more readily imbibed by, and com- 
bined with, the adjacent tissues. It is thus that some explain 
the yellow tinge observed on the mucous membrane of the 
duodenum in certain cases of poisoning by sulphuric acid. 

To sum up ; the gastro-intestinal mucous membrane is not 
of one constant and invariable colour in the healthy state. It 
is perfectly white only in a very small number of cases, which 
I have mentioned. Besides these it offers, without ceasing to 
be sound, different degrees of colouring, depending, 1. on the 



16 DISEASES OF THE ALIMENTARY CANAL 

passive hyperemia which has always a tendency to take place 
in the last moments of life in the parts abounding in capillaries ; 
2. on mechanical obstacles to the venous circulation formed at 
a longer or shorter period before death ; 3. on the hypostatic 
accumulation of blood towards the dependent parts ; 4. on the 
transudation of the blood through its vessels ; 5. on another 
kind of transudation which may take place, in some cases at 
least, through the capsule of the spleen ; 6. on the presence of 
different gases in the alimentary canal at the moment of death ; 
7. on the developement of other gases, at a longer or shorter 
period after death, when putrefaction takes place ; 8. on the 
combination of the yellow matter of the bile with different parts 
of the gastro-intestinal mucous membrane ; 9. and lastly, on 
the accidental introduction into the alimentary canal of differ- 
ent colouring principles that may stain its internal surface, and 
thus produce a colour more or less perfectly resembling the 
result of a morbid state. 

Of the colours produced by these different causes, some can- 
not be in any way confounded with that resulting from in- 
flammation; others differ from it only by characters which are 
often but feebly marked; and, lastly, others, especially those 
mentioned under the heads 1 and 3, as also some varieties of 
those under the heads 2 and 4, exactly resemble the colour that 
would result in the alimentary canal from the irritation artifi- 
cially produced in it by the introduction of a mineral acid suf- 
ficiently diluted with water to inject, without disorganizing, 
those portions of the tissues with which it comes in contact. 

It is, besides, important to observe that, ceteris paribus, the 
colour of the gastro-intestinal mucous membrane presents some 
shades, according to, 1. the part examined; 2. the age; and, 3. 
whether the process of digestion was going on or not in the 
stomach or in the duodenum and jejunum at the moment of 
death. Thus, in those cases in which the mucous membrane 
is found colourless in the adult, we may observe, as M. Billard 
has shewn us, that it is whitish in the stomach, of an ashy white 
in the duodenum and jejunum, that the ashy shade diminishes 
towards the end of the ileum, and that, finally, in the great in- 
testine, the mucous membrane resumes its dead white colour. 



BHLOW THE DIAPHRAGM. 17 

With respect to age, we learn from the valuable researches of 
M. Billard that the gastro-intestinal. mucous membrane is rose- 
coloured in the foetus and in the infant, and of a milky and satiny 
whiteness in young persons; that, in the adult, it assumes a 
slight ashy shade, especially in the duodenum and commence- 
ment of the small intestine ; and lastly, that in old age this ashy 
shade becomes more decided and general, whilst the submu- 
cous veins, being dilated and filled with blood, lift up and im- 
part a colour to the membrane covering them. At other times, 
however, in old persons who die in a decrepit and bloodless 
state, the mucous membrane is remarkable for its extreme pale- 
ness. I am even persuaded, that it is in old persons, and in 
very young children that had died of marasmus, that I have 
observed the internal surface of the alimentary canal in the 
most perfectly colourless state. 

I have already spoken of the modifications produced in the 
colour of this membrane by the process of digestion. 

The natural thickness and consistence of the mucous mem- 
brane of the alimentary canal are not less important to be de- 
termined precisely than its colour. 

This membrane, in its natural state, is far from being equally 
thick throughout. M. Billard has proved that the maximum of 
thickness exists in the duodenum, and the minimum in the 
colon. Between these two extremities we find, 1. the pyloric 
portion of the stomach, in which the mucous membrane of the 
stomach is almost as thick as the duodenum ; 2. its splenic por- 
tion, where its thickness is much less; 3. the rectum; 4. the 
jejunum ; 5. the ileum. The great thickness of the mucous 
membrane of the duodenum depends principally on the numer- 
ous follicles distributed through it; in the stomach, it is the 
body of the membrane itself which has an excess of thickness. 
M. Louis has attempted to measure exactly the relative thick- 
ness of the different portions of the mucous membrane of the 
stomach. Its thickness in the great curvature amounts, accord- 
ing to him, to three-fourths of a millimetre; in the small curva- 
ture, from a third to three-fourths; and in the great extremity, 
from a third to three-fifths, only. (A millimetre is .03937 of 
an English inch.) There are certain folds formed by the mu- 

Vol. II. 4 



18 DISEASES OF THE ALIMENTARY CANAL 

cous membrane, both in the stomach and elsewhere, which con- 
tribute to an apparent augmentation of its thickness. Where 
these folds exist, it often happens that there is a more extensive 
redness found, than in their intervals; this is observed, for in- 
stance, in the valvules conniventes of the small intestine. But 
when we separate the two reflected portions of membrane that 
constitute each valve, by drawing asunder their base at each 
side, the unfolded membrane does not appear any redder than 
the neighbouring parts. 

In the remarks I have just made on the thickness of the mu- 
cous membrane of the alimentary canal, I have supposed it to 
be examined in the body of a person that had died of an acute 
disease, and whose intestines were not gorged with too great 
a quantity of blood from one of the causes already pointed out. 
When that occurs, the thickness of the membrane may be in- 
creased by the blood which distends its vessels, without our 
being warranted in considering it as diseased on that account. 
On the other hand, in persons who die of marasmus, without 
having been affected with gastro-intestinal irritation, the mu- 
cous membrane of the alimentary canal becomes remarkably 
thin, falling into a state of atrophy along with the subjacent 
muscular coat: many other tissues are similarly affected, under 
the same circumstances. This attenuation is particularly re- 
markable in the stomach, whose mucous membrane, especially 
towards the great extremity, becomes reduced to an exceed- 
ingly fine kind of web. I grant that a membrane so attenuated 
as that is no longer in its physiological state, and that its func- 
tions must be deranged; it must digest but imperfectly, just as 
its muscular coat, under the same circumstances, must contract 
but imperfectly. At this degree, the attenuation of the pari- 
etes of the stomach becomes a morbid state; but before it 
reaches that state we may observe many other degrees in 
which the diminution of thickness of the mucous membrane of 
the stomach is physiologically proportionate to certain states 
of the general nutritive action. Lastly, I think it probable 
enough that great varieties of thickness of this mucous mem- 
brane must occur in individuals, just as is the case with the 



BELOW THE DIAPHRAGM. 19 

cutaneous system, and as there are also differences of bulk in 
the muscular and osseous systems in various individuals. 

The consistence of the gastro-intestinal mucous membrane 
is in general directly in proportion to its thickness. It is much 
more considerable in the pyloric portion of the stomach than 
in its splenic portion; in the colon, where the thickness of the 
mucous membrane is at its minimum, its consistence is also 
very slight. In the stomach, we may allow the mucous mem- 
brane to be of the natural thickness, when, on making an 
incision in it, taking care not to cut the subjacent tissues, es- 
pecially the nervous, or, more properly, the membranous coat, 
we can easily detach pretty considerable shreds of it with a 
forceps: the shreds should be larger in the pyloric than in the 
splenic portion. In the duodenum its nature is such as not to 
admit of such considerable shreds being detached as in the 
stomach. In the rest of the intestines, the rectum excepted, 
the mucous membrane, even in its natural state, breaks and 
tears whenever we attempt to detach any portion of it. In 
these various parts, however, the same physiological conditions 
which produce a variation in the thickness of the membrane, 
such as the quantity of blood supplying it, and the general state 
of the nutritive powers, produce a variation in its consistence. 
Thus, at the same time that this membrane becomes thinner, 
it tends also to grow softer, without the previous or present 
existence of any process of irritation. 

The mucous membrane of the alimentary canal may, after 
death, be modified in its consistence, as we have already seen 
it to be in its colour. This kind of softening has been observed 
principally in two cases: 1. long after death, when there were 
already signs of putrefaction in the body ; 2. in a very short 
period after death. 

In the first of these cases the membrane loses its consistence 
but slowly. I have more than once found it not in the slightest 
degree softened in bodies of persons that had been from eight 
to ten days dead, in which the intestines were green and dis- 
tended with gases, while there was exudation of blood into 
them, together with ecchymoses in the substance of their pa- 
rietes, and in many parts, emphysema under the membrane. 



20 DISEASES OF THE ALIMENTARY CANAL 

After the tenth day its consistence diminishes, and it then soft- 
ens gradually; from the fifteenth to the eighteenth day it 
becomes like pap, and from the twenty-fifth to the thirtieth it 
becomes quite undistinguishable. 

This membrane, when exposed to the air, softens much more 
rapidly. M. Billard, after opening an intestinal canal, left it 
extended on a table for twelve days; the temperature of the 
room was ten degrees above zero, and the sun shone into it 
every day. The mucous membrane did not begin to soften 
until the sixth day, at which period putrefaction was already 
advanced; on the tenth day it was of a pultaceous consistence; 
and, on the eleventh, it was reduced to a very fetid greenish 
pulp.- 

On the contrary, this membrane, when removed from the 
influence of the atmosphere by being placed under water, 
softens but very slowly. M. Billard, after leaving a portion 
of intestine for two months in the same water, and not till 
then, found its mucous membrane perceptibly softened, though 
it still retained a certain degree of consistence. It was not 
till three months had elapsed, that it was found to be so soft- 
ened as to resemble merely a kind of very fetid purulent 
layer. 

It follows from these facts that the post-mortem softening of 
the gastro-intestinal mucous membrane does not occur until 
the putrefaction is pretty far advanced, and after the usual pe- 
riod of opening bodies in most cases. It would appear, then, 
that we should not consider the very evident softening of the 
mucous membrane of the stomach, that is sometimes observed 
at from twenty to four and twenty hours after death, to have 
taken place after thSt event. However, the solution of this 
question is embarrassed, if I may say so, by some cases in 
which the mucous membrane of the stomach has been found 
completely softened, in dogs killed in very good health, and 
opened shortly after death. Similar facts have been observed 
by M. Bretonneau. M. Trousseau, who gives an account of 
them in the Archives de Mcdccine (torn. xii. page 345) adopts 
an opinion of Hunter's, who has numerous followers in Eng- 
land at the present day, and attributes this kind of softening to 



BELOW THE DIAPHRAGM. 21 

the solvent action of the juices secreted by the stomach. 
According to several English physicians, the softening might 
even extend to all the coats of the stomach, and produce a 
perforation of that viscus after death. The arguments on 
which they ground their opinion are the following. 

1. It has frequently occurred, that, on opening the bodies of 
men, and still more of various animals, the parietes of the 
stomach have been found singularly softened or perforated, al- 
though before death there had been no symptoms of any gas- 
tric affection, and most of them had been killed while appa- 
rently in the enjoyment of perfect health. Adams has found 
such perforations in the stomach of dogs ; Carlisle and Cooper, 
in those of rabbits ; and Spallanzani, in those of fishes. Be- 
fore that, Hunter had found the stomach perforated in a 
prisoner who had starved himself to death. 

2. In these cases no traces of peritonitis were discovered 
around the perforation ; which should necessarily have oc- 
curred, if the communication between the cavity of the 
stomach and that of the peritoneum had been formed during 
life. 

3. Doctor Allan Burns found, in a human body, the stomach 
perforated in that part where it is in contact with the liver. 
Having ascertained that the latter was uninjured, he proceed- 
ed, two days afterwards, to examine the parts anew, when he 
found that new changes had taken place; the portion of liver 
which supplied the place of the deficient parietes of the stom- 
ach was itself remarkably softened and broken down : still, 
there was as yet no sign of putrefaction in the body. In this 
case, as Mr. Burns observes, is it not evident that this kind of 
liquefaction of the liver was owing to the solvent action of the 
same juice which had previously attacked and destroyed a 
portion of the gastric parietes ? 

4. From a young man of a sound constitution, who had a 
fistula of the stomach in the epigastrium, in consequence of a 
gunshot wound, Dr. Lovell, surgeon in chief of the armies of 
the United States, collected a certain quantity of juice which 
flowed out through the fistula. The juice, which was received 
in a bottle, was put in contact with some meat, when it was 



22 



DISEASES OP THE ALIMENTARY CANAL 



observed that it dissolved it with great activity from the surface 
to the centre : the meat, says the narrator of the experiment, 
dissolved like a piece of gum arabic when kept in the mouth. 
Now, if the gastric juice is so active as that, is it not easy to 
conceive that if, after death, it happens to be in the stomach in 
a certain quantity, and possessing certain qualities, it may dis- 
solve the coats of that viscus, just as it dissolved the dead flesh, 
in the experiment? 

Are we then to admit, as proved by these facts, that the 
parietes of the stomach may be softened and perforated by the 
gastric juice after death ? I think, myself, that the facts should 
be taken into consideration, but that they are neither suffi- 
ciently numerous, nor circumstantially enough detailed, for us 
not to wait for new observations on the subject to confirm or 
contradict the conclusion drawn from them. 

As the follicles, both isolated and aggregated, that are dis- 
tributed over the gastro-intestinal mucous membrane, play a 
principal part in its diseases, it is of importance to determine 
accurately what varieties of appearance they may present 
without yet ceasing to be in their physiological state. 

In most adult subjects in which the alimentary canal does 
not appear to have undergone any alteration, very manifest 
follicles are found but in two parts ; namely, around the car- 
diac orifice of the stomach, and in the duodenum. Moreover 
in the inferior portion of the ileum, there are certain spots 
found where the parietes of the intestine seem to the touch to 
be thicker than elsewhere, and, on being placed between the 
eye and the light, have not the usual degree of transparency. 
It is there that those aggregated follicles known by the name 
of the glands of Peijer make their appearance in other 
subjects. 

In children the follicles are naturally more developed, and 
appear in a greater number of parts. Thus, in them, even 
when there has been no indication of the existence of any in- 
testinal affection, it is quite common to find on the internal 
surface both of the small and of the great intestine small round 
bodies, of a white or greyish colour, and with a central orifice, 
the circumference of which is very often of a deep grey; 



BELOW THE DIAPHRAGM. 23 

which are, very evidently, nothing but follicles. In many 
children, too, in whom the intestinal canal appears equally free 
from any morbid alteration, besides these isolated follicles, 
others are found crowded together, and lying close on one 
another in immense numbers, so as to form by their assem- 
blage very large patches that may occupy an extent of from 
one to three feet in the small intestine. In the centre of each 
follicle is often found a point of a bluish grey or black ; which 
produces a dotted appearance throughout the patch. As I 
have found these patches (the aggregated glands of Peyer) 
thus far developed, and thus coloured, in children who died 
suddenly in consequence of accidents, or of diseases that had 
no relation whatever to the digestive apparatus, I think I may 
assume as a fact that they do not constitute a morbid state in 
childhood. But are they a proof of disease in the adult ? It 
is true enough that, in many persons that die of or with chronic 
diarrhoea, the most remarkable and striking change found in 
the alimentary canal, is an unusual developement of the fol- 
licles, resembling what we have just now seen existing nat- 
urally in children. Besides, in many other individuals who 
died of some other disease while recovering from gastroen- 
teritis attended with severe symptoms, such as are termed 
adynamic and ataxic, I have often found on the internal sur- 
face of the alimentary canal, near the end of the ileum, the 
aggregated glands of Peyer appearing in the form of vast 
patches dotted with black. I believe that, in this latter case, 
the dotted patches discovered on examination after death, in- 
dicated that the follicles were in a state of hypertrophy, result- 
ing from the recent irritation that had affected them. But 
this state of hypertrophy might have continued without pro- 
ducing any bad effect ; as is proved by the fact that in many 
other adults the follicles are found in a similar state, although 
at the time of their death there had been no sort of disease in 
the prima via. To conclude, then, I think that the great de- 
velopement of the intestinal follicles is not a natural state in 
the adult : it may result from an antecedent process of acute 
inflammation, and continue as a vestige of such process ; it 
may also occur without any appreciable trace of antecedent 



24 DISEASES OF THE ALIMENTARY CANAL 

irritation, being connected simply with an increased action of 
the regular process of nutrition ; or, if you please, it may de- 
pend on the nutrition of these- follicles continuing to be as 
active in the adult as it was in the child. It is thus that the 
liver may continue as much developed in the adult as it was in 
the early period of its existence ; it is thus, too, that in a man 
of middle age, although free from disease, the different lymph- 
atic ganglions may be found as large as they are in children. 

It follows from these considerations that the intestinal folli- 
cles, as well those which are isolated as those which, by their 
aggregation towards the inferior portion of the ileum, form the 
plexus of Peyer, may, in the adult, be sometimes apparent, and 
sometimes almost imperceptible, without either of these states 
being really morbid ; so far as that each may occur without 
producing any disorder of the digestive functions. We learn, 
besides, from comparative anatomy, that a very great devel- 
opement of these follicles is natural in some animals. Thus, in 
most of the dogs that are sacrificed to physiological experi- 
ments, there are found in the small intestine numerous exten- 
sive patches dotted with black, exactly resembling those found 
also in the human subject, but yet so far from constantly, that 
when they are met with they are considered as morbid. They 
have been likewise observed in the intestinal canal of numbers 
of sheep killed in the slaughter-houses. I have also very often 
discovered them in horses ; but as I know not whether they 
had had any affection of the primce vice or not, I cannot, in their 
case, as in that of the other animals, bring forward the existence 
of these patches as a proof that they belonged to the healthy 
state. 

The tissues subjacent to the mucous membrane present, in 
the healthy state, the following characters. 

The submucous cellular tissue ought to have the appearance 
of a white layer, of a pretty great density, and traversed or 
not by a certain number of veins more or less gorged with 
blood. The muscular coat should be pale, resembling in colour 
the muscles of white blooded animals ; it should have its maxi- 
mum, of thickness in the pyloric portion of the stomach and in 
the rectum, and should appear thick in proportion to the con- 



BELOW THE DIAPHRAGM. 25 

traction of the intestine. In persons who die in a state of 
marasmus, without any chronic irritation of the intestinal canal, 
the gastro-intestinal muscular coat becomes remarkably wasted. 
The cellular tissue interposed between this coat and the peri- 
toneum is almost imperceptible in the healthy state : we must 
attend to this fact, because, in certain morbid states, this tissue 
may become hypertrophied, and contribute to the formation of 
various tumours. 

Nothing is more variable than the capacity of the intestines 
in different bodies. But, we must take particular notice that 
we may find the intestinal tube exceedingly narrowed, on the 
one hand, without its presenting any appreciable lesion ; and 
exceedingly wide, on the other, although presenting indubitable 
traces of irritation. Sometimes it is found narrowed in a sin- 
gular spot, so as to form a kind of strangulation ; while, either 
above or below it, the intestine is very wide : there is, however, 
no more trace of irritation in the contracted part than else- 
where. I have frequently observed a great whiteness on the 
internal surface of stomachs that were so shrunk as hardly to 
surpass the bulk of the colon. I have found that other stom- 
achs, which had been disorganized by the action of sulphuric 
acid, were very large. 

The internal surface of the alimentary canal ought to be lu- 
bricated, in the healthy state, by a moderate quantity of a grey- 
ish viscous mucus, capable of being collected, in form of a 
pretty consistent pulp, on the blade of the scalpel by slightly 
scraping the membrane with it. In the stomach, this mucus, 
when not mixed with the ingesta, is in a state of purity ; it ac- 
cumulates and is ultimately digested when no aliment has been 
taken for a long time. The secretion of this mucus is promo- 
ted by introducing some inert body into the stomach ; such as 
a pebble, round which it collects, or a sponge, which may then 
be withdrawn impregnated with it. In the small intestine, it is 
mixed with a certain quantity of bile ; in the great intestine its 
place is supplied by faeces, which are often found in great quan- 
tities in the colon of persons who yet have not eaten any thing 
for a long time. 

Vol. II. 5 



26 DISEASES OF THE ALIMENTAKY CANAL 



CHAPTER II. 



Of the Alimentary Canal considered in a State of Disease. 



In the preceding chapter we have studied the different ap- 
pearances the gastro-intestinal canal may present, and we have 
seen how much they may vary without there being a diseased 
state of the digestive passages. It is this diseased state which 
is now to engage our attention. In many instances we shall 
find that some of the alterations which belong to the morbid 
condition so exactly resemble some of the appearances of the 
healthy state as modified by one of the causes already enume- 
rated, that it will be impossible for us to distinguish them. We 
must then be content to remain in doubt, until new facts give 
us more light. At other times, we shall meet with conditions 
of the alimentary canal which we shall not hesitate to recog- 
nize as the results of disease ; but frequently another question 
will then arise, as to the nature of these unequivocally morbid 
states. Do they result from irritation, or, in other words, from 
an increased organic action of the tissue in which they are sit- 
uated 1 Or do they, on the contrary, depend on a diminution 
of this same organic action ? Or do they arise from neither of 
these causes, but merely from a perversion of the nutrition ? 
We shall sometimes be able to resolve these different ques- 
tions ; but, sometimes also, for want of a sufficient number of 
facts to judge from, we shall leave them undecided. For, no- 
thing tends more to give a false direction to a science than pre- 
suming to anticipate facts, and attempting to solve a problem 
of which we do not yet know all the elements. 

The different alterations that are about to engage our atten- 
tion may exist either separately or together: most of them are 
alternately cause and effect of each other ; but, in order to 
study them, it is absolutely necessary to consider them sepa- 
rately. 



BELOW THE DIAPHRAGM. 27 

Should we have designated by the common title of acute or 
chronic gastro-enteritis all the lesions which we are about to 
describe ? In my opinion that would have been prejudging 
the solution of more than one question that still remains unde- 
cided. I have considered it more advantageous to the sci- 
ence to avoid making use of this expression, which has lost its 
value from the single circumstance of its being too general. 
We shall, therefore, describe separately the different lesions 
which have latterly been comprehended under this generic 
term ; and we shall find that they are always lesions of circu- 
lation, nutrition, or secretion. In speaking of each, we shall 
endeavour to discover its nature, and to estimate the part, 
whether principal, secondary, or none at all, which irritation 
plays in its production ; and that, not only when we can use 
direct proof, but also when we can argue only from analogy 
or induction. 



ARTICLE I. 



LESIONS OP CIRCULATION. 



§ 1. Hyperemia of the Alimentary Canal. 



In the preceding chapter we have seen how numerous are 
the varieties of vascular injection which the alimentary canal 
may present, without our being warranted to consider it dis- 
eased ; the injection taking place either during the last strug- 
gle or after death. However, the red injection of the alimen- 
tary canal also may occur under the influence of a morbid 
state of any description whatever. We must therefore en- 
deavour to determine what varieties of injection may be pro- 



28 DISEASES OF THE ALIMENTARY CANAL 

duced in it by irritation or any other morbid condition, and to 
see how far they can be distinguished from those which may 
take place after death. 

For this purpose, we must select cases in which a foreign 
body, applied during life to the gastro-intestinal mucous mem- 
brane, has modified its circulation, and, by drawing to it more 
blood than usual, has produced in it a morbid state. Now the 
appearances that have been observed, with respect to colour, 
in the alimentary canal of men or animals, after the introduc- 
tion of irritating poisons into their stomach, are a simple injec- 
tion of vessels, which, according as they are more or less 
crowded, present either a very finely arborescent appearance, 
or a capilliform or ramiform network ; in other cases, a uni- 
form colour, either red, brown, or black ; and, in others, effu- 
sions of blood on the free surface of the mucous membrane, 
or beneath it. Sometimes the villi do not participate in these 
various degrees of injection, and sometimes they do. 

These different colourings are precisely similar to those we 
have seen produced independently of any morbid process. 
When, therefore, we meet with any such appearances, I grant 
we must allow they may, whatever be the shade, be the result 
of a morbid process ; but at the same time we must not forget 
that there is not one of them which may not also result purely 
from changes after death. 

Hence follows this very important principle, namely, that the 
single fact of the red colour of the alimentary canal is not suffi- 
cient to prove the previous existence of disease in that part ; 
so that an intestine that is found red in the dead body, was not 
necessarily so during life. 

Hyperasmia of the alimentary canal is generally confined to 
the mucous membrane. Nothing is more common than to find, 
underneath a portion of this membrane of an intense red colour, 
the subjacent cellular tissue perfectly white, and the other 
coats equally devoid of colour. Hence it follows that we can- 
not judge of the state of redness or paleness of the intestinal 
canal from examining it only externally : it frequently happens 
that, in such cases, its parietes appear pale, and the different 
tunics external to the mucous membrane are really so ; but the 



BELOW THE DIAPHRAGM. 



29 



membrane itself may be of more or less intense red, without 
its being perceived until the intestine be opened. 

Independently of its forms and seat, whether in the vessels 
of different sizes that run between the coats of the alimentary 
canal, or in those various coats themselves, gastro-intestinal 
hyperemia, considered only in the mucous membrane, may 
present three varieties, according as it affects principally the 
tissue of the membrane itself, its villi, or the follicles scattered 
through it. 

The first variety presents nothing remarkable in its forms, 
which may be very different. The second is distinguished by 
its dotted form : on examining the internal surface of the canal 
where this variety exists, we find it overspread with a number 
of small red points, which are often so crowded as to render 
the mucous membrane perfectly opaque. An attentive exam- 
ination will convince us that each of these red points consists 
of the summit of one of the villi ; a fact which becomes par- 
ticularly evident when the examination is made under water, 
as the innumerable filaments constituting the villi then become 
very apparent ; sometimes they are coloured only at their free 
extremity, and sometimes through their whole extent. In cer- 
tain cases the injection is confined solely to the villi, and there 
is no trace of it in the membranous tissue from the surface of 
which they arise, and in which they are in a manner inserted. 

Instead of a red colour, the villi of the gastro-intestinal mu- 
cous membrane not unfrequently present a brown or even deep 
black tint. I have often found the internal surface of the ali- 
mentary canal of a fine black colour, in the bodies of individ- 
uals that have been labouring under chronic diarrhoea ; and in 
some cases of this description I have satisfied myself that this 
unusual tinge was situated in the villi of the mucous membrane. 
I have also frequently found the villi in the alimentary canal 
of the horse, of a beautiful ebony black colour. This black 
tint of the villi runs through a series of shades into the red, 
which we may perceive becoming insensibly brown, and grad- 
ually arriving at the deepest black. We have, elsewhere, seen 
that there is often no other condition requisite for this change 
of colour to take place, than a simple diminution in the velocity 



30 DISEASES OP TIIE ALIMENTARY CANAL. 

of the capillary circulation. I believe, further, that this black 
tint of the villi, as well as the red, may be the result of irrita- 
tion of the digestive mucous membrane, as is proved by the 
fact that in most of the cases in which I observed such a tint, 
it was in the bodies of persons who had been affected with diar- 
rhoea for a greater or less length of time. 

Hypersemia from irritation does not occur with equal fre- 
quency in all parts of the alimentary canal. Those in which 
it is most' frequently met with are the stomach and the lower 
portion of the ileum. After these come, successively, the 
caecum, the colon, the rectum, the duodenum, the superior part 
of the ileum, and the jejunum. 

Hypersemia without any other alteration belongs to the acute 
and the chronic state. In more than one case in which the 
individual had for a very long time been presenting signs of 
an intestinal irritation, on opening the body after death I have 
found only a simple congestion, without any lesion in the tex- 
ture of the membranes ; in other cases, on the contrary, a few 
days are sufficient for a slight hypersemia to be succeeded 
either by softening or ulceration. 

It would be difficult to comprehend within a few species the 
numerous varieties of form which gastro-intestinal hyperasmia 
assumes. I think, however, I may point out the following 
species, which I distinguish by the appearance of the parts af- 
fected. 

In the first species, the light can still be seen through the 
membranes, between the vessels, which are disposed in a form 
more or less finely arborescent. 

In the second, the light is totally intercepted, and the opacity 
complete. In these two species the redness that appears on 
the internal surface of the intestine is disposed in dots, patches, 
spots, streaks, or bands. It is sometimes lost insensibly, and 
sometimes ceases abruptly. 

Again, hypersemia may be divided into three kinds, accord- 
ing as it is situated in the capillaries and larger vessels, or, 
lastly, in the larger vessels only. 

Of these three kinds, the first belongs almost exclusively to 
a state of irritation, and is an almost certain proof of its exist- 



BELOW THE DIAPHRAGM. 31 

ence. The second belongs equally to a state of irritation, and 
to a state of congestion from a mechanical cause that has acted 
during life or after death. The third kind but rarely depends 
on this last cause ; but yet neither does it announce a state of 
irritation similar to that which produces a hyperaemia of the 
capillaries solely. In fact, when the congestion is thus confin- 
ed to seme of the tolerably large vessels that are distributed in 
or under the gastro-intestinal mucous membrane, we have 
reason to think it belongs to a state of irritation that is on the 
decline ; and we may even admit that in such cases all irrita- 
tive process has completely disappeared, and that the blood 
which is still found accumulated in some vessels, having been 
distended by the unusual quantity of blood that traversed them 
as long as the irritation continued, remain passively dilated 
after all irritation has disappeared. This is what often takes 
place in the mucous membrane of the eye, in which, long after 
the capillaries of the conjunctiva have ceased to admit blood, 
some large red vessels still continue to appear on that mem- 
brane. It then frequently happens, that it is by applying sub- 
stances of a less stimulating nature to the conjunctiva that these 
vessels are forced to resume their natural dimensions, and to 
get rid of the blood which constantly tends to dilate them. May 
not this help to account for the success which sometimes at- 
tends a tonic mode of treatment when employed towards the 
end of certain kinds of irritation of the alimentary canal ? 

Hyperaemia of the follicles is not less remarkable in its form 
than that of the villi. On it, seem to me to depend those red 
circles which sometimes are found scattered over the stomach 
or intestines. These circles, which are apparently formed by 
very small vessels interlaced in various ways, circumscribe a 
slight elevation of the mucous membrane, which is owing to 
the presence of a follicle. It often happens, that, while the 
circumference of the follicle is thus defined by a vascular circle, 
another, smaller, but equally red, crowns, in a manner, the 
margin of its central orifice ; this circle, like the preceding, con- 
sists of an assemblage of small vessels most minutely injected. 
We may find in the same intestine a great number of follicles 
which are thus injected only at their circumference and centre, 



32 DISEASES OP THE ALIMENTARY CANAL 

while they remain white in the rest of their extent. Frequent- 
ly, too, both the red circle of the circumference, and that of 
the central orifice, become larger, approach each other as they 
increase in size, and at last meet ; which produces a uniformly 
red colour in several of the follicles. At other times, instead 
of these red circles, we observe some of a brown or black 
colour, which present in other respects the same arrangement. 
In certain cases, however, there is nothing to prove strictly 
that a follicle exists where the coloured circles in question 
make their appearance ; as there is no prominence to be ob- 
served within the circle, no depression towards tlie central 
red point. If in such cases we admit the existence of a follicu- 
lar hyperaemia, it can be only by analogy. 

The different shades of active hyperaemia of which we have 
now been speaking may be developed at all ages. They have 
been found even in the foetus, and in newly born children. In 
such cases, however, we should take care not to confound hy- 
peraemia from irritation, with simple mechanical congestion, 
which many causes may very, easily produce in the infant at 
birth. In the latter case the stomach and intestines are found 
more or less injected ; but the injection resembles that observ- 
ed in persons with aneurism. The mesenteric veins, the liver, 
the lungs, and the heart, are gorged with blood. How short 
soever be the interval between death and the examination of 
the body, we find, both in the stomach and intestine, the blood 
extravasated, and effused sometimes beneath the mucous mem- 
brane, and sometimes into the interior of the canal. How im- 
portant it is to be acquainted with these cases, in order to dis- 
tinguish them from those in which the colouring of the alimen- 
tary canal of the foetus, or of the new-born infant, depends on 
a real process of irritation ! 

The hyperaemia produced during life by a process of irrita-l 
tion proceeds, in its formation, in the reverse direction of the 
mechanical congestions. In the latter, the injection commen- 
ces with the great veins, and spreads from these to the capil- 
laries. In active congestion, on the contrary, it most frequent- 
ly happens that we find only the capillaries injected, while the 
vessels of larger diameter are devoid of colour. Moreover, 



BELOW THE DIAPHRAGM. 33 

there are in active hyperemia several degrees whose existence 
may serve to announce either its stage of increase or its stage 
of decline. In the first of these stages, it presents two degrees: 
the one, constituting the capilliform or reticular injection ; the 
other, that in which the vessels become so crowded, that every 
transparent interval disappears, and nothing is visible but a 
uniform red tint. In the stage of decline, we first remark, at 
the return from the second towards the first degree of the in- 
creasing stage, the arborescent or reticular injection. What is 
called the capilliform injection disappears, then the vascular 
network becomes less and less distinct, and at last vanishes ; 
and where it existed we observe only a few vessels of consider- 
able dimensions, which may remain dilated and filled with 
blood for a longer or shorter time after all process of irritation 
has ceased. It may happen, however, that, without any previ- 
ous injection of the capillaries, one or more of the pretty large 
vessels which run in the substance of the gastro-intestinal pa- 
rietes may become injected ; and the ramiform injection is then 
a primitive condition : the same thing is sometimes to be ob- 
served in the conjunctiva. 

It would be of importance to be able to distinguish the cases 
in which the colouring of the alimentary canal depends, 1. on 
an irritation originally chronic ; 2. on a chronic, which has suc- 
ceeded to an acute irritation ; 3. on an acute irritation grafted 
on a chronic. But it is not yet possible rigorously to establish 
such distinctions ; all that can be said is, that the brown, grey, 
and slate colour, specially belong to chronic irritation. We 
must not, however, forget, that the introduction into the stom- 
achs of animals, of irritating substances that speedily destroyed 
life, has often produced in the mucous membrane of the stomach 
a brown tint resembling that generally connected with the ex- 
istence of chronic irritation. As to the red colour, it belongs 
no less to chronic, than to acute irritation. I shall bring for- 
ward no other proof of this than the case of a man, fifty-one 
years of age, who died at La Charite after labouring under 
diarrhoea for eight months. We observed him wasting away 
without the abdomen ever feeling painful, or fever lighting up 
for a single instant. He had only four or five liquid stools, and 
Vol. II. 6 ' 



34 DISEASES OP THE ALIMENTARY CANAL 

often less, in the four and twenty hours: he had the greatest 
repugnance to all kinds of food. On opening the body, the 
internal surface of the stomach was found to be of a brown 
colour, which was situated in the thickened mucous membrane. 
The mucous membrane of the small intestine was of a deep 
red, in about the upper four-fifths of its extent: the lower fifth 
presented merely a slight appearance of injection. The inter- 
nal surface of the caecum was white. The mucous membrane 
of the colon and of the beginning of the rectum was spotted 
with a multitude of red patches, of an oval or roundish form, 
which completely intercepted the light. Thus, all that was 
found in the body of a man who had died in the last degree of 
marasmus and exhaustion, was a little more blood in the gastro- 
intestinal mucous membrane than usual, tinging that membrane 
brown in the stomach, and red in the rest of the alimentary 
canal. 



§ II. Ancemia of the Alimentary Canal. 



This lesion, upon which the attention of observers has hith- 
erto been but little fixed, is not very rare. Its anatomical char- 
acter is an extreme paleness of the alimentary canal, either 
throughout its whole extent, or in some parts only. It is usually 
accompanied by a more or less considerable attenuation of the 
gastric or intestinal parietes. We seldom observe it but in 
the bodies of persons who have died exhausted by various 
chronic diseases, or who sink while convalescent from a severe 
fever. In this last case, it sometimes happens that at the same 
time that we find the alimentary canal completely devoid of 
blood, we discover in it ulcers which are as pale as the sur- 
rounding tissue. I have also met with this coexistence of 
anaemia and ulceration in several young children, who, after 
having suffered under diarrhoea, had gradually wasted away 
and died comatose. 



BELOW THE DIAPHRAGM. 35 



ARTICLE II. 



LESIONS OF NUTRITION. 



§ I. Hypertrophy of the Alimentary Canal. 



This hypertrophy may exist simultaneously in the different 
coats of the stomach, or be confined to some of them, or even 
may involve but one of the anatomical elements of the mucous 
membrane, such as the follicles. In these different cases, the 
gastro-intestinal parietes assume very varied aspects, so differ- 
ent, indeed, that they have often been considered varieties of 
diseases. Frequently, also, the real nature of the alterations 
produced by hypertrophy of one or more of the coats of the 
stomach or intestines has been mistaken ; for instance, some 
have considered as new tissues, developed in the substance of 
the gastro-intestinal parietes, these parietes themselves, though 
having undergone no change but simple hypertrophy in some 
of their coats. Thus, the name of cancer has been given to a 
mere thickening of the submucous cellular tissue, &c. ; as well 
might the name have been given to the thickening of the cel- 
lular tissue which surrounds old cutaneous ulcers, or to the in- 
duration which affects the interlobular cellular tissue in certain 
diseases of the lungs. 

We shall now follow this hypertrophy successively through 
the different coats of which the aggregate constitutes the gas- 
tro-intestinal parietes. 

A. Hypertrophy of the Mucous Membrane. 

Real hypertrophy of the mucous membrane must be distin- 
guished from the thickening it may present in the case of sim- 



36 DISEASES OF THE ALIMENTARY CANAL 

pie hyperemia, in which more blood than usual stagnates in the 
mucous membrane, which becomes tumefied, but its nutrition 
has not been really increased. 

When the gastro-intestinal mucous membrane is really in a 
state of hypertrophy, it is at the same time harder and more 
resisting than in the natural condition: it maybe removed in 
large shreds without tearing, and the cellular tissue which sep- 
arates it from the muscular coat remains uninjured beneath. 

Hypertrophy of the mucous membrane both of the stomach 
and intestines may be accompanied by different shades of col- 
ouring which it is important to notice. Thus, it may exist, 1. 
with retention of the usual colour of the membrane, which is 
a rare case; 2. with different degrees of redness; 3. with a 
slate-coloured tint ; and 4. with a brown or even black tint. 

Hypertrophy of the mucous membrane is more common in 
the stomach and great intestine than in the small intestine, and 
may be either general or circumscribed in these different parts. 
Thus, for example, it is not uncommon to find the mucous mem- 
brane of the stomach in a state of hypertrophy through its 
whole extent : the membrane, while becoming thicker, some- 
times preserves a smooth and uniform appearance ; sometimes, 
being increased unequally, it presents a number of elevations 
separated by sinuous depressions; it then assumes a papillary 
appearance. In the large intestine, the general hypertrophy 
of the mucous membrane is sometimes so great, that it alone 
exceeds in thickness all the other coats taken together. 

When hypertrophy of the mucous membrane occupies only 
isolated points, that is, in other words, when it is partial or cir- 
cumscribed, it produces on the internal surface of the stomach 
or intestines, elevations, projections, patches, and tumours, of 
various forms, sizes, and textures. 

It is not very uncommon to find, on the internal surface of 
the stomach, irregular patches, rising only from half a line to 
two lines above the level of the rest of the membrane, and 
sometimes of the same colour with it, sometimes red, brown, 
or grey, and lastly sometimes of a deader white than the rest 
of the membrane. I have twice found some of the patches of 
a milk-white tint. They may be round, somewhat oval, or 



BELOW THE DIAPHRAGM. 37 

elongated. If we cut into them, and examine their structure, 
we become satisfied that they consist solely of the mucous 
membrane, which is merely in a state of hypertrophy in these 
particular spots. These patches differ in their nature from 
other patches which it is not unusual to meet with towards the 
termination of the small intestine, and which are owing to a 
morbid condition of the follicles. Instead of simple patches, 
the mucous membrane may become affected with hypertrophy 
in such a manner that there shall appear on its surface different 
productions which have been designated by the names of ex- 
crescences, vegetations, fungi, polypi, and cancers; and/which 
are nothing but various forms of hypertrophy of the mucous 
membrane, as any one may satisfy hWself by an attentive dis- 
section. The word excrescence indicates well enough the re- 
sult of this kind of process, in which we observe on the surface 
of the mucous membrane a real growth of its different anatom- 
ical elements. 

The varieties of appearance of these partial hypertrophies 
depend on the differences they may present in form or texture. 

The varieties of texture shall now engage our particular at- 
tention. The mucous membrane, while shooting up above its 
surface, or vegetating, may either preserve its usual consistence, 
become much harder, or, lastly, present several degrees of soft- 
ening: it may be pale, or display all possible shades of colour; 
it may receive but little blood, or be traversed by numbers of 
vessels, and by veins which, from their gorged and dilated 
state, sometimes resemble varices, or, from their interlacement 
and the facility with which the blood escapes from their inte- 
rior, represent a sort of erectile tissue. According to these 
different textures, different names have been given to the cir- 
cumscribed hypertrophies of the gatro-intestinal mucous mem- 
brane ; they have been denominated vegetations, fungi, polypi, 
scirrhi, &c. 

Many of these names have also been employed to designate 
varieties of form of these productions. Some, for instance, 
are of equal size throughout, being sometimes globular, some- 
times cylindrical, and sometimes not resembling any geometric- 
al figure. I once saw a stomach of which the internal sur- 



38 DISEASES OF THE ALIMENTARY CANAL 

face was furnished with numbers of laminae placed side by side 
edgewise, and at right angles to the longitudinal axis of the 
stomach, which were formed solely by an unusual develope- 
ment of the mucous membrane. They rose fully from two to 
five lines above the level of the membrane ; and might be ex- 
actly enough compared to the laminae which, in ruminating 
animals, characterize that portion of the stomach which has 
received the name of maniplies. Other excrescences are not of 
equal size through their whole extent. Considered at their ad- 
herent extremity, they are to be distinguished into those which 
have a base of greater or less extent where they are continu- 
ous with the mucous membrane, and those which are connected 
by a more slender portion* called a pedicle, which may contain 
only some capillaries, or afford a passage to vessels of consid- 
able size. With regard to their other extremity, these excres- 
cences present still more varieties of form. Some terminate 
in a point; others are rounded at their free extremity; while 
others swell out considerably, and form a kind of head resemb- 
ling that of a mushroom or of a cauliflower. 

These excrescences, in all the varieties just described, have 
been observed in every part of the alimentary canal from the 
cardiac orifice to the anus. In the stomach, they are to be dis- 
tinguished into those which occupy, 1. one of the surfaces of 
the organ ; 2. its cardiac orifice ; and, 3. its pyloric orifice. 
They are much more uncommon in the duodenum and small 
intestine than in the stomach ; however M. Billard once found 
in a new-born infant, near the middle of the second curvature 
of the duodenum, a pedunculated excrescence, which was red 
and irregularly shaped like a strawberry. It was of the size of 
an ordinary kidneybean, and was firmly attached by its stalk to 
the surface of the mucous membrane. It was remarkable for 
the great quantity of blood it contained. The excrescences 
become more frequent, but yet less so than in the stomach, to- 
wards the caecum, colon, and commencement of the rectum ; 
finally, in the inferior part of this last intestine they are to be 
met with more frequently than any where else ; and it is de- 
serving of remark that, towards the anal orifice, they are often 
produced by a special cause, namely, the syphilitic virus. 



BELOW THE DIAPHRAGM. 39 

With respect to their number, they are sometimes solitary, 
there being but one to be found in the whole extent of the in- 
testinal tube ; and sometimes many, whether in the same por- 
tion, or in different parts, of the intestines. Thus, I found once 
on the internal surface of a stomach seven vegetations, each of 
about the size of .a walnut, which all resembled each other in 
texture and form, and adhered by a pretty broad base to the 
mucous membrane, of which they were merely a developement. 
They were traversed by numbers of vessels, and terminated in 
a broad head with an unequal surface of a kind of papillary ap- 
pearance, with the margin, very much turned down. Six of 
these excrescences occupied the middle of the stomach ; the 
seventh was situated near the pylorus. The mucous mem- 
brane of the intervening spaces was not altered in any appre- 
ciable manner. M. Rullier presented to the Acad&nie Royale 
de Medecine a stomach whose surface was studded with about 
eighty small round tumours, each of the bulk of a filbert, of firm 
tissue, and evidently formed at the expense of the mucous 
membrane, of which they were merely small portions in a state 
of hypertrophy and induration. I once found the caecum stud- 
ded with a score of small conical bodies, of a violet red colour, 
each of which were nearly as large as a small bean. On dis- 
section I found that their tissue was exactly similar to that of 
the mucous membrane, of which they were evidently prolon- 
gations. Lastly, it is not very unusual to meet with such de- 
velopements of the mucous membrane at the same time in the 
stomach and in some part of the intestine, especially towards 
its ileo-csecal portion. I might here bring forward the case of 
a man who died at La Charite, whose body I did not see till 
after death. From the internal surface of the stomach, near 
the pylorus, there sprung a large vegetation, resembling a 
mushroom ; near the point of junction of the jejunum and ileum 
was another of the same kind ; and, lastly, a little above the 
caecum was a third excrescence, which resembled the other 
two both in form and texture. 

In place of involving the whole of the proper texture of the 
gastro-intestinal mucous membrane, it may happen that the hy- 
pertrophy shall occur only in a greater or less number of the 



40 DISEASES OP THE ALIMENTARY CANAL 

villi which cover its free surface. Several of these villi, of a 
much greater size than ordinary, have been sometimes observed 
projecting considerably above the mucous membrane, from 
which they differed by their colour being of a deader white, 
and by forming small tumours, the nature of which was easily 
to be discovered by an attentive examinatiqn. It is possible 
that many vegetations of the gastro-intestinal mucous mem- 
brane may be owing to a hypertrophy of some of the villi. 

The villi, however, have been less frequently discovered in 
a state of hypertrophy than the follicles. The unusual devel- 
opement of these small bodies often gives rise to the formation 
of tumours which, in form, arrangement, and structure, seem 
so different from the follicles, that their origin might easily be 
mistaken. One is not disposed to refer them to a simple hy- 
pertrophy of the follicles, until he has followed these in the 
series of transformations they undergo in proportion to the in- 
crease and developement of the different anatomical elements 
that enter into their composition. 

We have already seen that, in the alimentary canal of 
children, the follicles are naturally more apparent than in the 
adult. Hence it follows that, in adults, whenever the internal 
surface of this canal is found studded with very apparent fol- 
licles, we are to consider their developement as a morbid 
state. 

The follicles of the intestinal tube may be much more ap- 
parent than ordinary, and project above the free surface of the 
mucous membrane, without being in a true state of hyper- 
trophy. This is what happens in those cases where, in conse- 
quence of an acute or chronic inflammation of the canal, the 
follicles spread over it become the seat of a more or less con- 
siderable active hypersemia. Being then gorged with blood, 
they become tumid, and form on the internal surface of the in- 
testine a greater or less number of small conical elevations, 
which frequently exhibit a central orifice that has been often 
taken for an ulcer. These are isolated where the follicles are 
so ; and are confluent, and form by their assemblage large 
patches elevated above the level of the mucous membrane, 



BELOW THE DIA.FimA.GM. 41 

where the follicles are aggregated ; constituting the rlothinen- 
teritis of M. Brctonneau. 

From the single circumstance of the follicles of the alimen- 
tary canal having been affected by a hypersemia of variable in- 
tensity and duration, their nutrition acquires a greater activity. 
After the cessation of the hyperscmia, they still continue to in- 
crease in bulk, or else retain the bulk they had acquired while 
congested, and they are then really in a state of hypertrophy. 
In this case, the hypertrophy succeeds an evident hyperaemia. 
I have observed this remarkable developement of the follicles 
in bodies of persons who had all the signs of gastro-intestinal 
irritation at a more or less remote period before their death. 
The internal surface of the mucous membrane was studded 
with small, conical, whitish bodies, tolerably hard, and most of 
them with an evident central orifice : the mucous membrane 
between them did not exhibit any appreciable alteration. In 
some of these individuals, there had not been any derangement 
of the digestive functions for a long time ; so that the hyper- 
trophy of the intestinal follicles had not produced any function- 
al disorder in them : others had been frequently affected with 
diarrhoea, which used to cease at intervals, and return again 
with the greatest facility: in others, lastly, the diarrhoea had 
been constant ; and yet in these there was nothing found but 
an unusual developement of the follicles, just as in the first 
mentioned ; but then the follicles had at the same time ac- 
quired a greater activity of secretion, which was the cause of 
the diarrhoea whether intermittent or constant. 

In the cases we have now examined, the hypertrophy of the 
follicles has been preceded by a state of acute hyperoemia ; 
but that affection may also take place insensibly, without any 
signs of antecedent hyperseraia, just as we often see certain 
cutaneous follicles becoming larger, without their ever having 
been the seat of any appreciable sanguineous congestion. In 
this case, as in the preceding, sometimes there has never been 
any diarrhoea, while at other times it has appeared, either at 
intervals, or constantly. Hypertrophy of a great number of 
follicles may be the only alteration found in the alimentary 
Vol. II. 7 



42 DISEASES OF THE ALIMENTARY CANAL 

canal of persons that have been continually affected with 
diarrhoea for the last six months or the last year of their life. 

The orifice of the enlarged follicles often retains its natural 
size ; in other cases it grows wider ; and lastly, in others, it 
grows narrower, tends to become obliterated, and even ac- 
tually does become so. The enlargement of the orifice is 
sometimes so considerable that the mouth of the follicle be- 
comes as wide as the bottom ; in which case the follicle might 
easily be mistaken for an ulcer. In other cases, as I have al- 
ready remarked, while the parietes of the follicle become en- 
larged and thickened, its orifice diminishes and becomes ef- 
faced. The result is, that the fluid secreted in its interior 
constantly accumulates, and voluminous tumours are thus grad- 
ually formed : such are often found in the intestines of horses. 
I have seen some in the stomach of these animals that were as 
large as an orange. Their real nature might easily be mis- 
taken, were it not that, in most cases, the orifice of the follicle 
may be discovered on attentive examination, and a probe in- 
troduced, so as afterwards mechanically to enlarge it. It is 
true that, in some cases, the orifice cannot be found, being, as 
it would appear, completely obliterated. 

At the same time that the portion of mucous membrane that 
constitutes the parietes of a muciparous follicle becomes affect- 
ed with hypertrophy, that kind of cellulo-fibrous tissue which 
lines them, as it does the rest of the mucous membrane, not 
only becomes similarly affected, and indurated, but is also often 
transformed into fibrous, fibro-cartilaginous, or cartilaginous 
tissue, which surrounds the follicles on all sides, and consider- 
ably augments the thickness of its parietes. These tumours 
occur much less frequently in man than in the horse : 
M. Dupuy has found similar ones in dogs, sheep, and pigs. 

Hypertrophy of the follicles does not occur with equal 
frequency in every part of the alimentary canal. Thus, it 
is found oftener in the inferior part of the small intestine 
than any where else. In the stomach, it is very uncommon. 
M. Billard, however, saw, in a child ten months old, the mucous 
membrane of the stomach studded throughout its whole extent 
with a prodigious number of white granules, of about the size 



EELOW THE DIAPHRAGM. 43 

of a grain of millet. There were similar ones in the whole 
course of the intestines. Were these follicles ? 

We must take care not to confound with follicles in a state of 
hypertrophy certain small whitish bodies which are sometimes 
found scattered on the internal surface of the intestines, and 
which at first sight greatly resemble such follicle. These are 
nothing but rudiments of valvules conniventes, on or between 
which they are situated. Some tufts of the villi, of a deader 
white than those around them, might also be sometimes mis- 
taken for follicles. 



B. Hypertrophy of the Tissues subjacent to the Mucous 
Membrane. 



This kind of hypertrophy may affect, 1. the cellular tissue 
interposed between the different coats of the gastro-intestinal 
parietes; and, 2. the muscular coat. 

Writers have long described under the name of scirrhus of 
the stomach or intestines a certain state of those parts consisting 
merely of an increase of thickness and density in the cellular 
membrane which, in the natural condition, separates the mu- 
cous membrane from the muscular tunic. Any one may con- 
vince himself of this by following the hypertrophy of this kind 
of cellular tissue through all its stages. In the first place, in 
many cases of chronic diarrhoea, where the mucous membrane 
of the great intestine has undergone various kinds of alterations, 
the cellular tissue which lines it is often found much more ap- 
parent than usual; in such cases, it is sometimes several lines 
in thickness, so as of itself to surpass that of all the other coats 
taken together: it is hard, of a pearly white, and without any 
blood vessels ; sometimes there may be observed in it fibres or 
plates more or less regularly arranged; and sometimes it ex- 
hibits nothing but a homogeneous texture, pretty like that of 
imperfect cartilage. As long as this cellular layer is of little 
thickness, it is considered only as indurated cellular tissue, sim- 
ilar to that which surrounds old cutaneous ulcers, or appears 



44 DISEASES OF THE ALIMENTARY CAKAZ 

between the pulmonary lobules in certain cases of chronic af- 
fections of the respiratory organs. There is often interposed 
between the mucous and muscular coats, from the commence- 
ment of the colon to the rectum, a white layer of from half a 
line to two lines in thickness. This, again, is considered mere- 
ly as an induration of the submucous cellular tissue. 

But, when the hypertrophy is more considerable, and at the 
same time more circumscribed; when, in short, it forms in 
some one point, of the intestinal tube a real tumour which raises 
up the mucous membrane, it is then no longer denominated in- 
duration, nor hypertrophy, but scirrhus. In this case, how- 
ever, the alteration is the same as in the preceding ones ; the 
cellular tunic has become ten times as thick as natural in a 
circumscribed point, instead of becoming twice as thick through- 
out a great extent: there lies the whole difference. The same 
disposition, texture, and anatomical elements, are to be found 
in the whitish layer that lines the mucous membrane of the 
great intestine, as in the bulky tumour that obstructs the cardia 
or the pylorus. Writers, then, may, if they please, give the 
name of scirrhus to such a tumour, provided that they come 
to an understanding as to the meaning of the word, and ac- 
knowledge that in this case the scirrhus is not a new tissue, 
without any thing analogous in the healthy state, and created, 
like an entozoon, in the parietes of the stomach or intestines; 
but that it is simply the result of a hypertrophy of the submu- 
cous cellular tissue, which may either continue to be the sole 
lesion, or may subsequently become complicated with other 
alterations of nutrition or secretion. In fact, a new structure 
often does develope itself in the cellular tissue thus affected 
with hypertrophy ; numerous vessels make their appearance in 
it; it becomes divided into lobes, or hollowed into cells or 
areolae ; and, lastly, various morbid secretions take place. 

On examining the parietes of the stomach or intestine where 
the submucous cellular tissue is affected with hypertrophy, we 
often find that the affection is not confined to that tissue only; 
but, in the substance of the muscular tunic there appear white 
lines, or true partitions of a cellulo-fibrous appearance, which 
are interposed from space to space between the lacerti of the 



BELOW THE DIAPHRAGM. 



45 



muscles, thus isolating them from each other, and giving the 
tunic a kind of lobulated appearance. These partitions are 
continuous, on the one hand, with the submucous cellular tis- 
sue, and on the other, with another cellular layer, interposed 
between the muscu'ir tunic and the peritoneum: they are 
evidently nothing but portions of the intermuscular cellular tis- 
sue in a state of hypertrophy. But, the hypertrophy may be- 
come more considerable; and in place of simple lines or thin 
plates, it may happen that we shall find scattered through the 
substance of the muscular coat certain hard white masses of 
more or less considerable size, which are still nothing but the 
same cellular tissue in a state of hypertrophy ; these also in- 
crease, and eventually take up more room than the muscular 
coat itself, which becomes less and less apparent, until a period 
arrives when, at most, a few muscular fibres can be discovered 
scattered at wide intervals through enormous masses of indu- 
rated cellular tissue, in the substance of which they are in a 
manner imbedded ; at last all appearance of muscle is lost, and 
there is nothing to be found between the peritoneum and the 
mucous membrane but a mass of cellular tissue, either simply 
in a state of hypertrophy and induration, or having become the 
seat of various alterations consecutively. 

Hypertrophy of the submucous cellular tissue is, in general, 
only developed subsequently to a state of chronic irritation of 
the mucous membrane, although none of the numerous varie- 
ties of such irritation necessarily determine its formation. It 
may, however, happen, that there is no appreciable lesion to 
be discovered in the mucous membrane, either because such 
lesion has long ceased to exist, or even, in some cases, because 
it never did exist. In other cases, the mucous membrane is 
found in a state of hyperemia, induration, or softening ; and, 
lastly, in others, in a state of ulceration. There are even cases 
in which there is not the least trace of this membrane to be 
met with in the whole part corresponding to the hypertrophied 
portion of the cellular tissue. 

Hypertrophy of the submucous cellular tissue has been ob- 
served in every part of that portion of the alimentary canal 



46 DISEASES OF THE ALIMENTARY CANAL 

that is beneath the diaphragm. We shall first turn our atten- 
tion to it as it exists in the stomach. 

There are some cases in which the submucous cellular tis- 
sue is considerably thickened throughout the whole extent of 
this organ. In such cases, on touchiog the parietes of the 
stomach, one is struck with their hardness. They do not 
yield, as in the natural state ; and they offer a sufficient resist- 
ance to the knife to grate under it. Outside the thickened 
cellular layer, the muscular tunic is sometimes found in its 
natural condition, and sometimes divided into lobules by fibro- 
cellular intersections ; in a state of hypertrophy, or, on the con- 
trary, in such a state of atrophy, that there is not a trace of it 
left, so that there is nothing to be found between the mucous 
coat and the peritoneum but a mass of indurated cellular tis- 
sue. The cavity of the stomach is then usually but of small 
dimensions. 

There are, again, other cases in which the hypertrophy of 
the submucous cellular tissue takes place only in a circum- 
scribed part of the stomach, which is sometimes one or other 
of its faces, and sometimes one of its orifices. Of the various 
parts of the stomach, that of which the cellular tissue is most 
frequently affected, is incontestably its pyloric extremity, as 
well as the pylorus itself. Any one that has been at all con- 
versant with anatomical researches must have met with some 
of those cases in which, for an extent of two or three finger's 
breadths on the gastric side of the pylorus, there is a tumour, 
which is sometimes perceptible only in the interior of the 
stomach, and sometimes projects exteriorly, so as to be dis- 
coverable through the abdominal parieties : this tumour pro- 
ceeds from hypertrophy of the cellular tissue. Various other 
lesions may coexist with this, and modify the nature of the tu- 
mour, but they do not affect its form or bulk. As we approach 
the splenic portion of the stomach, we find the cellular tissue 
gradually diminishing in thickness, and resuming its natural ap- 
pearance. Sometimes the hypertrophy is strictly confined to 
the pyloric ring, and on each side of it there is nothing morbid 
to be seen in the submucous cellular tissue. In these va- 
rious cases, the duodenal orifice of the stomach may exhibit 



BELOW THE DIAPHRAGM. 47 

three different conditions: 1. it may have preserved its usual di- 
ameter ; 2. it may be narrowed ; 3. and lastly, it may be dilated. 

When the first of these conditions exists, the stomach does 
not change either in form or in bulk ; the ingesta do not accu- 
mulate in it, and vomiting may not occur, though the pylorus or 
neighbouring parts may be the seat of a tumour discoverable 
during life through the abdominal parietes. 

When the second condition occurs, a very remarkable phe- 
nomenon is observed : the solid of fluid substances introduced 
into the stomach not being able to pass the pylorus without the 
greatest difficulty, accumulate in that viscus, which, being thus 
continually distended, at last acquires an enormous bulk. I 
have elsewhere (Clinique medicale) detailed cases of this de- 
scription : in one, the stomach became so large as to cover the 
whole of the intestines, and to reach the os pubis with its great 
curvature. Such a great increase of bulk is rather uncommon ; 
but stomachs are pretty often found which reach as low as the 
navel in consequence of the contraction of the duodenal orifice. 
On such occasions, the parietes of the stomach are sometimes 
considerably attenuated, and sometimes of their usual thick- 
ness, in which case we must admit that they are even in a 
state of hypertrophy, since their surface is much greater with- 
out their thickness being diminished. 

When the stomach is thus distended, it may retain the sub- 
stances introduced into it for several days: they fill it as they 
would an inert bag ; and on giving the body of the patient a 
brisk shake, a very distinct rumbling is produced. At last a 
period arrives when the stomach, being distended beyond 
measure, empties itself by disgorging its contents ; and hence 
arise those vomitings, so remarkable for their extreme copious- 
ness, which supervene from time to time, every eight or ten 
days, for instance, in persons affected with the disease at present 
under consideration. 

Lastly, when the third condition exists, that, namely, in 
which there is at the same time hypertrophy of the submucous 
cellular tissue of the pyloric portion of the stomach, and preter- 
natural enlargement of the duodenal orifice, the rest of the 
stomach may retain its natural bulk ; but, the contrary may 



48 DISEASES OF THE ALIMENTARY CANAL 

also take place, and, in more than one instance, a dilated state 
of the pylorus has been observed to co-exist with a consider- 
able augmentation of the capacity of the stomach, equal to 
what it is capable of acquiring in the case of the tendency to 
the obliteration of the duodenal orifice. That orifice then di- 
lates along with the rest of the stomach, at the same time that 
its parietes are affected with hypertrophy, just as a considerable 
enlargement of the cavity of the heart or of the aorta is in gene- 
ral accompanied by an increase of thickness of their parietes. 

I do not know an instance where the hypertrophy has been 
found to be confined to the submucous cellular tissue of the 
great extremity of the stomach exclusively; but it has been 
found involving the circumference, of the cardiac orifice, 
without affecting the rest of the viscus. How inconsiderable 
soever this may be, it has the effect of narrowing the orifice ; 
which prevents the substances swallowed from arriving freely 
into the cavity of the stomach. The affection may be confined 
solely to the circumference of the cardia, or extend to the in- 
ferior part of the oesophagus. 

Hypertrophy of the submucous cellular tissue of the small 
intestine is much less frequent than hypertrophy of the submu- 
cous cellular tissue of the stomach. When it is found there, it 
generally occupies but a small extent, where it forms a tumour 
which is sometimes confined to one of the sides of the intes- 
tine, and sometimes engages its whole circumference. In both 
these cases, especially in the second, the cavity of the intestine 
is more or less considerably contracted, and its contents pass 
on without difficulty. In such cases, although the lesion is 
constant, a remarkable intermission is often observed in the 
symptoms that announce the existence of an obstacle to the 
course of the fsecal matter. After several months of obstinate 
constipation, during which all the symptoms of internal strangu- 
lation with severe pain in some spot of the abdomen have fre- 
quently appeared, it sometimes happens that all these symp- 
toms, however, return anew, and each time with increased 
severity; and the patient often dies during such a relapse. 
These singular intermissions can be explained only by suppos- 
ing that the tumour formed by the hypertrophy of the cellular 



BELOW THE DIAPHRAGM. 49 

tissue merely diminishes the calibre of the intestine, without 
obliterating its cavity entirely ; and that such obliteration re- 
sults from the momentary tumefaction of the portion of the 
mucous membrane which lines the affected cellular tissue. 

The submucous cellular tissue of the great intestine is more 
frequently affected with hypertrophy than that of the small in- 
testine ; and, as in the case of the stomach, the affection may 
be general, or confined to some one spot. The same effects 
are produced as in the small intestine. Obstruction to the 
course of the faecal matter arising from circumscribed hyper- 
trophy of the submucous cellular tissue has been more fre- 
quently observed in the ascending and descending portions of 
the colon than in the transverse ; and it is observed still more 
so in the lower part of the rectum. This last is even, next to 
the stomach, the place where the species of lesion under con- 
sideration most frequently occurs : the result is one of the va- 
rieties of that complicated alteration that has been designated 
by the name of cancer of the rectum. 

In certain cases, hypertrophy of the submucous cellular tis- 
sue exists to a high degree about the anus, producing without 
and around that orifice a greater or less tumefaction, that pro- 
jects like a cluster of haemorrhoids, which it greatly resembles. 
In place of a circular tumefaction, there sometimes exist 
around the anus some isolated tumours which also resemble 
haemorrhoids. On dissecting each kind, they are found to be 
composed, proceeding from without inwards, 1. of the mucous 
membrane, more or less injected ; and, 2. of the submucous 
cellular tissue, considerably thickened, and forming the tumour. 
At a later period, this cellular tissue may become constantly 
more indurated, or may soften, suppurate, ulcerate, &c, as also 
may the mucous membrane itself; whence result various kinds 
of alterations designated by the generic term cancer. A short 
time ago, on opening the body of a person whose anus was 
thus surrounded by tumours of an hsemorrhoidal appearance, 
which were composed of nothing but masses of cellular tissue 
in a state of hypertrophy, I found the whole internal surface of 
the rectum studded with tumours of a similar description. 
Their appearance reminded me of those great tubercles of the 
Vol. II. 8 



50 DISEASES OF THE ALIMENTARY CANAL 

skin which characterize one of the varieties of elephantiasis. 
They formed, on the free surface of the intestine, globular 
bodies of a livid red. Like the tumours of the anus, they were 
composed of the submucous cellular tissue considerably thick- 
ened ; beneath this the muscular coat was found untouched ; 
and above it was the mucous membrane, which was red, and 
somewhat tumid. Some vessels of a pretty considerable size 
rose perpendicularly from the muscular coat, traversed the cel- 
lular mass, and distributed themselves over the mucous mem- 
brane. 

Hypertrophy of the submucous cellular tissue does not ap- 
pear with equal frequency at all ages. It is very rare in in- 
fancy; however, in a child about a year old, I found on one 
spot in the small intestine a tumour as large as a filbert, which 
was composed of this tissue in a state of hypertrophy: the 
mucous membrane covering it was unaltered. 

M. Billard found a considerable thickening of the submucous 
cellular tissue in a child six days old, which had come into the 
world in a very advanced state of marasmus, and was affected 
with a copious diarrhoea and a slight jaundice. The parietes 
of the end of the ileum and of the colon were very much thick- 
ened, which was entirely owing to the hypertrophy of the sub- 
mucous cellular tissue, which had at the same time a whitish 
and pearly appearance. The mucous membrane was also 
somewhat thick, very red, and remarkably friable. 

I have also several times discovered hypertrophy of this tis- 
sue through the whole of the great intestine in children of from 
four to twelve years of age, that had been affected with chronic 
diarrhoea. From the period of puberty until towards the 
thirty-fifth year, this affection is very rare. I once, however, 
found, at La Charite, in a young man twenty-two years of age, 
a voluminous tumour which occupied the pyloric portion of the 
stomach, and which consisted of a mass of cellular tissue in a 
state of hypertrophy. The patient had had, for the three pre- 
ceding years, all the symptoms of an organic affection of the 
stomach. At nineteen his digestion began to be deranged ; he 
was tormented with acid risings in his mouth, and had a feel- 
ing of weight about the region of the stomach, immediately 



BELOW THE DIAPHRAGM. 51 

after taking food. He fell away daily, but did not vomit. At 
twenty-one he began to experience frequent nausea, and from 
time to time threw up his food and drink. These vomitings 
became more and more frequent; and when he entered La 
Cliarite, which was only a few months before his death, he 
vomited almost every day, and a tumour could be distinctly 
felt in the ep'igastrium, to the right of the ensiform cartilage. 

After the age of thirty-five years it becomes much more 
usual to find chronic irritation of the mucous membrane of the 
alimentary canal, the stomach especially, succeeded by hyper- 
trophy of the submucous cellular tissue. After sixty-five this 
affection again begins to appear more rarely ; and in old peo- 
ple who die after having long suffered from painful digestion, 
it is much less frequently found than softening of the mucous 
membrane and the subjacent tissues. Thus it may be estab- 
lished as a general principle, that it is between thirty-five and 
sixty-five that the lesion under consideration most frequently 
occurs. Cases of it have, however, been observed up to a 
very advanced age ; and I might here relate one of an old man 
of seventy-nine, who died at La Cliarite, in whom was found, 
in the whole pyloric portion of the stomach, a hypertrophy of 
the submucous cellular tissue, considerable' enough to produce 
a tumor projecting into the cavity of the organ. The mucous 
membrane above it was free from all appreciable alteration, 

At the same time that the cellular tissue exhibits the state of 
hypertrophy we have just been studying, the muscular coat, as 
we have said, often becomes less apparent, and there are even 
instances where there are no traces of it to be found. But ex- 
actly the reverse case may occur, and the increase of thickness 
of the cellular layers of the stomach is sometimes accompanied 
by a considerable state of hypertrophy of the muscular coat. 
In such cases, on making a clean incision through the thickened 
parietes of the stomach, we find, proceeding from within out- 
wards, 1. the mucous membrane, sometimes sound, and some- 
times altered in various ways ; 2. immediately beneath this, a 
layer of a milky white, varying in thickness from less than a 
line to several inches ; this is the submucous cellular tissue; 3. 
beneath this layer appears another, distinguished by its bluish 



52 DISEASES OF THE ALIMENTARY CANAL 

colour, semitransparent, and with a peculiar kind of lustre ; it 
is traversed by lines exactly similar in colour and appearance 
to the preceding layer ; this is evidently the muscular coat in 
a state of hypertrophy ; 4. and lastly, still more externally there 
may appear a second layer of a dead white colour, and homo- 
geneous texture, resembling the layer situated immediately be- 
neath the mucous membrane : this is, in fact, the subperitoneal 
cellular tissue, which has become thickened and indurated like 
the submucous. Thus, in this instance, hypertrophy of the mus- 
cular coat accompanies the thickening of the cellular layers 
which enter into the composition of the gastro-intestinal par- 
ietes. But, in others, the cellular tissue remains untouched, 
and the muscular coat alone is affected ; and may be so much 
so as to produce a considerable thickening of the parietes of 
the stomach or intestines. It is in the pyloric portion of the 
stomach especially that this kind of hypertrophy has been ob- 
served ; and that is also one of the parts where, in the natural 
condition, the muscular coat of the alimentary canal is of the 
greatest thickness, and its action most remarkable. In fact, . 
on opening the abdomen of a living animal, we find that the 
right quarter of the stomach, the pylorus, and the commence- 
ment of the duodenum, are continually animated with a con- 
tractile motion which is propagated from the stomach towards 
the duodenum, and from that back again. This motion is most 
distinct during the process of chymification ; whence it follows 
that whatever tends to excite the mucous membrane must tend 
to increase the action of the muscular fibres of the pyloric por- 
tion, and must consequently also have a tendency to produce 
in them a state of hypertrophy. Dr. Rene Prus* observes 
that the frequent vomitings that occur in some patients labour- 
ing under a chronic irritation of the gastric mucous membrane 
may greatly contribute to the production of the hypertrophy 
of the muscular coat of the stomach. 



* Recherches sur la Nature et h Traitement du Cancer de V Estomac ; par Ren£ 
Prus, 1828. 



BELOW THE DIAPHRAGM. 53 

The lesions we have just pointed out are those which have 
long been, and are still every day, described under the name of 
scirrhus of the stomach. We can now see in what this scirrhus 
consists, which is, in a great many cases, merely a hypertrophy 
of one or more of the submucous layers of the stomach, produ- 
cing a constant modification in their consistence and colour, and, 
moreover, frequently accompanied by various alterations of 
secretion to be pointed out farther on. 

We have now examined the part that each of the tunics of 
the alimentary canal bears in the hypertrophy of its parietes ; 
but we have not yet arrived at the last term of the analysis, if I 
may use the expression ; we have still to inquire if this affec- 
tion may not also attack, more or less separately, 1. the blood 
vessels that run in the substance of the parietes of the alimenta- 
ry canal ; 2. its lymphatic apparatus ; and, 3. its nerves. 

There is nothing more common than to find some vessels 
both in the stomach and intestines, in a state of dilatation ; but 
this is not hypertrophy. Sometimes, however, their parietes 
are in a most evident state of hypertrophy ; thus, in two cases 
of chronic affections of the stomach, I discovered a considera- 
ble thickening in the parietes of two veins which ran, gorged 
with blood, beneath the mucous membrane. 

As to the hypertrophy of that portion of the lymphatic sys- 
tem which carries the chyle or the lymph from the alimentary 
canal, pathologists have long been acquainted with it. In fact, 
what else but hypertrophy is that evident increase of volume, 
together with redness or paleness of their tissue, exhibited by 
the mesenteric ganglions in most cases where the intestinal mu- 
cous membrane has been the seat of irritation more or less 
prolonged ? Undoubtedly, at the commencement of such irri- 
tation, the tumefaction of the mesenteric ganglions depends 
simply on sanguineous congestion, and hypertrophy has not yet 
taken place ; but it occurs subsequently, whether the irritation 
continues or ceases. Indeed, this affection of the ganglions 
often remains as a trace and indication of the intestinal irrita- 
tion which produced it, and which has long completely disap- 
peared. In some cases, these ganglions, at the same time that 
they are in a state of hypertrophy, are also affected with hyper- 



54 DISEASES OF THE ALIMENTARY CANAL 

aemia ; in others, on the contrary, they are pale and even more 
colourless than in their natural condition ; so that the only un- 
usual appearance they present is an increase of size. 

The ganglions which receive the lymphatic vessels of the 
stomach, are much less frequently affected with hypertrophy 
than those of the mesentery ; some of them, however, are oc- 
casionally found large enough, along the great or small curva- 
ture of the stomach, or around the pylorus. . 

I have often carefully examined the nerves of animal or or- 
ganic life that are distributed over the gastro-intestinal pari- 
etes ; and have never been able to discover the least alteration 
in them. However M. Rene Prus* has had an opportunity of 
observing a case in which one of the branches of the pneumo- 
gastric was evidently affected with hypertrophy, near its ter- 
mination on the stomach. The subject was a man of fifty-two 
years of age, who fell a victim to a tedious disease of the stom- 
ach, during which he exhibited all the symptoms of a so called 
cancerous affection of that viscus. The mucous membrane 
was found but little altered ; the submucous cellular tissue was 
of a dead white, of the consistence of lard, and considerably 
thickened ; and the muscular coat was very much affected 
with hypertrophy. These different alterations existed in the 
body of the stomach, for an extent of about three inches trans- 
versely ; the pylorus and cardia remained free. A tumour, 
which had been discovered during life, was the result. In this 
terminated the right cesophagean branch of the pneumogastric, 
which, from the cardia to the superior part of the tumour, had 
increased to twice its bulk, without change of colour or consist- 
ence ; it then entered the tumour, where it was no longer pos- 
sible to follow it. 



§ II. Atrophy of the Alimentary Canal. 



This may take place either in the whole of the layers that 
compose the gastro-intestinal parietes, or in one only. 



* Op, cit. page 86. 



BELOW THE DIAPHRAGM. 55 

Atrophy of the mucous membrane presents two degrees. In 
the first, it is characterized by the diminished size of the villi ; 
sometimes, even, there is no trace of them to be found. In the 
second, the texture of the membrane itself is singularly atten- 
uated, and it resembles a fine web, pretty like the delicate 
membrane that lines the maxillary sinuses. The obliteration of 
the villi is sometimes general and sometimes partial. When 
the latter is the case, they are not to be found in some spots, 
while they are well developed in the intervening spaces. This 
partial absence of the villi may depend on two causes; either 
on a simple state of atrophy of the mucous membrane, or on 
cicatrized ulcers where there has been nothing as yet repro- 
duced but the tissue of the membrane. 

Atrophy of the mucous membrane is observed pretty often 
in cases of chronic diseases ; it may accompany either a state 
of anaemia, of hypersemia, ulcers, or other alterations of texture. 

The muscular coat is also subject to atrophy. The fleshy 
fibres which compose it then become much less apparent ; their 
fasciculi are separated by intervals occupied by cellular tissue; 
and sometimes it is not without difficulty that a few of them 
can be found scattered up and down, thin, pale, and hardly to 
be distinguished from the cellular tissue in the substance of 
which they are in a manner distributed. 

Atrophy of the muscular coat may coexist with atrophy of 
the other coats; but it may, on the contrary, also occur while 
others are in a state of hypertrophy. Thus, the thickening of 
the submucous cellular tissue is frequently accompanied by an 
almost total disappearance of the muscular coat. We have 
already, in the preceding paragraph, taken notice of this kind 
of balance of nutrition. 

Lastly, the atrophy may exist at once in all the tunics of the 
gastro-intestinal parietes ; these are then singularly attenuated, 
so as to appear to be composed merely of a very delicate sero- 
cellular tissue, transparent and colourless : in fact, all that is to 
be seen is, exteriorly, a serous membrane, and, interiorly, a 
smooth layer, without villi, apparent vessels, or follicles, and no 
longer distinctly possessing the characters of mucous mem- 
brane. 



56 DISEASES OF THE ALIMENTARY CANAL 

The splenic portion of the stomach is pretty frequently the 
seat of this kind of atrophy; next to that, it is most commonly 
found in the inferior portion of the small intestine. 



§ III. Softening of the Alimentary Canal. 



One of the most frequent alterations observed in the parietes 
of the alimentary canal is the diminution of consistence of one 
or more of the coats which form them. 

Of these various coats, the mucous is that which most fre- 
quently becomes soft. It may have lost its consistence to such 
a degree, that there is nothing to be found in its place, for a 
greater or less extent, but a liquid pulp; without, however, the 
consistence of the other coats being in the least diminished. 
In other cases, all the membranes are simultaneously affected 
with the softening; and then we find that the parietes of the 
stomach or of some part of the intestines may be torn with the 
greatest ease by the slightest pull. 

I shall now describe successively, 1. the softening of the 
mucous membrane alone ; and, 2. the simultaneous softening of 
all the coats. 



Of the Softening of the Mucous Membrane alone. 



We have already attempted, in a preceding article, to esti- 
mate the varieties of consistence that this membrane should 
naturally exhibit in its different situations; and from what we 
said it follows, that a degree of consistence such as to be nat- 
ural in the colon, for instance, becomes, in the stomach or duod- 
enum, a morbid softening. 

Softening of the digestive mucous membrane is particularly 
remarkable in the stomach ; accordingly it is in this organ it 
has been most particularly attended to by modern anatomists. 



BELOW THE DIAPHRAGM. 57 

When the mucous membrane of the stomach begins to soften, 
it becomes impossible to take it off in shreds. It is reduced to 
a pulpy substance by the gripe of the forceps on attempting to 
detach it ; and the slightest attempt to scrape it off immedi- 
ately converts it into a kind of pap. Even in this state, how- 
ever, it still exists, as a membrane, over the whole stomach. 
But, as its softening increases, a period arrives when, before 
touching it, it is found to be reduced to a pulp, of an unorgan- 
ized appearance, which seems like mucus deposited on the in- 
ternal surface of the stomach. At a more advanced stage, 
even this pnlp is no longer found uniformly spread over the 
whole extent of the gastric surface; in certain parts it is de- 
ficient, and in its place is found the bare submucous cellular 
tissue, possessed of all its usual qualities. Lastly, still later, the 
parts where the pulp is deficient increase in number, and there 
are only to be seen a few worn fragments of the mucous layer 
scattered here and there; every where else there is nothing 
visible but the submucous cellular tissue, which retains its ordi- 
nary whiteness and density. 

This affection may prevail through the entire extent of the 
stomach ; and there are cases in which it has been well ascer- 
tained that the mucous membrane of almost the whole of that 
viscus, having been reduced to a diffluent pulp, had disappear- 
ed. From the cardia to the pylorus, the internal surface of the 
stomach almost throughout presented nothing but the cellular 
layer, which was thus immediately in contact with the ingesta. 

It oftener happens that the softening of the gastric mucous 
membrane is partial, and it is then more frequently observed 
towards the splenic portion of the stomach. The softening of 
the mucous membrane of this portion is very often accom- 
panied by a state of dilatation of the veins which run between 
the coats of the great extremity of the stomach ; in such cases 
they are visible on its exterior, and their presence has more 
than once announced a softening of the gastric mucous mem- 
brane, before the stomach was opened. 

This affection is occasionally still more circumscribed, and 
occurs only in isolated patches, of which there are sometimes 
but one or two, and sometimes a great number, the mucous 
Vol. II. 9 



58 DISEASES OF THE ALIMENTARY CANAL 

membrane between them remaining in its natural condition. 
M. Sestier, resident physician at the Hbpital des Enfans- 
Trouves, shewed me the stomach of a child, on the internal 
surface of which were ten small patches of a pale red colour, 
and exactly circular form. They were on a level with the rest 
of the surface of the membrane, and were each of about the 
diameter of a half franc piece. Where these were, the mu- 
cous membrane could be reduced by the slightest touch to a 
sort of diffluent pulp, beneath which the other membranes ap- 
peared uninjured : between them, it was free from any ap- 
preciable alteration. I have seen other cases where similar 
patches, instead of being red, were of a deader white than the 
rest of the membrane ; had they been in the least depressed 
beneath its surface, they might easily have been taken for ul- 
cers. These circumscribed softenings, when thus confined to 
the mucous membrane, may be the origin of certain ulcers 
there : when extended to all the coats of the stomach, they 
may be the cause of many perforations of that viscus. 

In place of these circumscribed softenings, disposed in more 
or less regularly circular patches, we sometimes observe an- 
other form of the affection, in which the mucous membrane 
exhibits a certain number of lines, streaks, or sinuous bands, 
where it has lost its consistence, and is at the same time in a 
manner sunk ; we then find on the internal surface of the stom- 
ach a kind of furrows where one would think at first that the 
mucous membrane was destroyed, while in reality it is only 
softened. 

Softening of the mucous membrane of the stomach is ac- 
companied by various shades of colouring, which it is import- 
ant to note. In this respect, the following cases may ofFer 
themselves. 

Case I. The mucous membrane, while softened in various 
degrees, may exhibit a greyish tint exactly resembling its 
colour in the natural state. When that happens,. if one was to 
content himself with examining the internal surface of the 
stomach, without applying the scalpel to the mucous mem- 
brane, he might consider as sound a stomach that was deeply 
diseased. 



BELOW THE DIAPHRAGM. 59 

Case II. The softened mucous membrane may be of a paler 
tint than that of the natural state ; and it then often has a bluish 
shade through it. 

Case III. It is sometimes found of a dead, or milky white. 

Case IV. Lastly, it may happen to be of a red or brown 
colour, which is sometimes uniformly spread over the whole of 
the softened portion, and sometimes appears on it only in 
points or spots. 

Softening of the mucous membrane of the stomach is a lesion 
that may be produced either by an acute, or by a chronic pro- 
cess. The introduction of irritating poisons into the stomach 
often causes it to take place in a few hours, and the mucous 
membrane becomes at the same time strongly injected. 

In many chronic diseases, especially of the lungs, a period 
arrives when the patients lose their appetite, and digestion be- 
comes difficult ; as for the rest, they have neither nausea, vom- 
iting, nor pain in the epigastrium, nor is the appearance of the 
tongue altered. The lesion most frequently found in the stom- 
ach under such circumstances is a softening of the mucous 
membrane, together with one of the shades of colouring above 
described. 

Sometimes, instead of commencing slowly, and announcing 
its presence only by slightly marked symptoms, the softening 
takes place by a .more acute process, and its existence is indi- 
cated by pain in the epigastrium, vomiting, and redness of the 
tongue. In such cases it is found to be accompanied by a bright 
redness of the membrane. 

Softening of the mucous membrane of the stomach appears 
to me to be a common affection in old people whose digestion 
becomes disordered, their health having previously been very 
good. Their appetite first diminishes, they then lose it entirely, 
and, soon after, they begin to feel the greatest dislike to all 
kinds of food. They experience a constant feeling of uneasi- 
ness and weight, rather than actual pain, in the region of the 
stomach ; and their tongue, which is usually natural, or else 
more or less thickly coated, grows red and dry occasionally. 
This state may continue for several months ; the pulse then 
becomes more frequent, a considerable emaciation takes place, 



GO DISEASES OF THE ALIMENTARY CANAL 

the strength rapidly declines, and the patients die without 
showing symptoms of a serious affection of any organ up to 
the last moments. On opening the body, there is nothing found 
but a more or less considerable softening of the mucous mem- 
brane of the stomach, with or without injection of its tissue. 

We have just seen that in many cases where, after death, 
the gastric mucous membrane is found softened in various de- 
grees, there has not been any pain in the epigastrium during 
life ; or, at most, the patients have complained only of a kind 
of disturbance, uneasiness or weight in that region. Some, 
.however, have, for a long time had very severe pain in the 
epigastrium, and yet no other lesion could be discovered in 
their stomachs, after death, than in those of the others. Here, 
then, is another case where the difference of the symptoms is 
in no wise explained by the difference of the alterations. 

What has been said of the softening of the mucous mem- 
brane of the stomach applies exactly to the softening of that 
membrane in the rest of the intestinal canal. I shall therefore 
content myself with drawing the reader's attention to those 
cases of pretty frequent occurrence in which the eye cannot 
detect any perceptible lesion on the internal surface of the in- 
testines, the caecum and colon especially, although there has 
been a copious diarrhoea during life. Here, one would at first 
be inclined to allow that the affection took place without any 
lesion of the intestine ; but, on applying the scalpel to the mu- 
cous membrane, and attempting to detach it, he will in most 
cases be struck with its extreme softness, and he will sometimes 
even find it reduced to a pulp devoid of all traces of organiza- 
tion. Thus, then, in certain chronic diarrhoeas, the only alter- 
ation observed in the alimentary canal is a white softening of 
the mucous membrane of the end of the small, or of the great 
intestine. 



II. Softening of all the Layers of the Gastro-intestinal Parietes. 

In some cases, the parietes of the stomach and intestines 
are found liable to be torn by the slightest pull. If we then 



BELOW THE DIAPHRAGM. 61 

examine them where the solution of continuity has taken place, 
or make a fresh perforation by pressing them gently with the 
finger, we find that the mucous, muscular, and serous coats, 
together with the various interposed cellular layers, have lost 
their usual appearance, and become soft, friable, and in a man- 
ner dissolved ; and that they not unfrequently resemble a kind 
of transparent jelly, which scarcely preserves the appearance 
of an organized texture. This is that remarkable lesion to 
which M. Cruveilhier, who has described it with the greatest 
accuracy, has given the name of gelatiniform softening (" ra- 
mollissement gelatiniforme"). In such cases, before touching 
the parietes of the stomach or intestines, one would often take 
them to be quite sound, as they are modified only in respect 
to their consistence. 

This general softening of all the coats may, like that of the 
mucous membrane only, take place, 1. their natural colour 
being preserved ; 2. they being remarkably pale ; and, 3. their 
tissue being red. 

The splenic portion of the stomach is the part where the 
species of softening at present under consideration has most 
frequently been observed. I saw it involving the whole of the 
stomach in two children, of whom one had taken some sul- 
phuret of potash a few months before his death, and the other 
had died with the various symptoms which characterize acute 
hydrocephalus. In the first of these cases, the whole of the 
parietes of the stomach resembled the pulpy part of a red 
cherry ; there had been constant vomiting during life. In the 
second, the child was in good health, when, without any known 
cause, he was seized with vomiting, which, after having con- 
tinued for two days, was succeeded by convulsions, and at 
last by a comatose state, in which he died, five or six days 
after the first attack. The stomach was found to be softened 
to such a degree through its whole extent, that wherever 
pressure was made on its parietes, they were reduced to a 
pap, and torn ; but this stomach, very unlike the other, was 
remarkably pale throughout ; and yet the progress of the dis- 
ease had been acute. 



62 DISEASES OF THE ALIMENTARY CANAL 

Softening of all the coats has also been found in various 
parts of the. small intestine, caecum, and colon. 

It has been observed to occur at every age ; M. Cruveilhier 
saw it prevail epidemically at Limoges among young children ; 
and other authors have related cases of it at all periods of life. 

We now come to the question whether softening of the pari- 
etes of the stomach or intestines, as well as when confined to a 
single coat, as when extended to all, takes place only during 
life ; whether there are not cases where it is merely produced 
after death; and, whether, in the first place, it may not be some- 
times the result of putrefaction. It is an undoubted fact that, 
in proportion as a body putrefies, the tissues composing it grad- 
ually lose their consistence, as is particularly evident in the va- 
rious parenchymatous organs : thus on opening a body ever so 
soon after from thirty to thirty-five hours after death, in a low 
temperature, and even sooner in a high, we find the brain, lungs, 
liver, spleen, and kidneys, evidently softened. If we then ex- 
amine the parietes of the alimentary canal, we shall find that 
they still retain a great degree of consistence, even while the 
parts already mentioned are much softened : the mucous mem- 
brane, in particular, does not "begin to soften until signs of ad- 
vanced putrefaction have appeared in other parts of the body ; 
whence, I think, we ought to conclude that whenever we dis- 
cover the mucous membrane to be ever so little softened, with- 
out there being as yet any traces of putrefaction in the body, we 
should not attribute it to that cause.* 

It may, then, he established as a general principle, that any 
softening observed in the parietes of the alimentary canal on 
opening the body at the usual period after death, should not be 
considered as the result of putrefaction. But, are we to con- 
clude from this, that every time it is met with, it is to be consid- 
ered as having taken place during life ? To this question, 
some reply that a considerable softening of the parietes of the 
stomach may take place after death, not from putrefaction, but 



* Vid. page 20, for an account of the experiments of M. Billard relative to the 
softening of the parietes of the alimentary canal by putrefaction. 



BELOW THE DIAPHRAGM. 



63 



from other causes which do not act until life has terminated. In 
a thesis maintained in Germany, by Camerer, before Professor 
Autenreith, (Stuttgard, 1818,) we find an account of several 
examinations of bodies of rabbits and cats, that had been killed 
while in very good health; in which it is stated that in all of 
them the great extremity of the stomach was softened, and its 
parietes were in a manner dissolved, and even, when a suffi- 
cient time had elapsed after death, perforated. Yet, when 
these examinations were made, the bodies did not shew the least 
sign of putrefaction ; while, on the contrary, in the body of a 
dog already putrefied, there was no trace of softening in the 
stomach. We see, then, that Camerer discovered this affec- 
tion in the bodies of healthy animals, before decomposition had 
commenced ; but did not find it in animals that had died of dis- 
ease, nor in those that died a lingering death. It happened 
only in those cases where an animal in good health was kilied in 
a short time after the reception of food into the stomach, and 
during the process of chymification. Can this be, as Hunter 
taught, owing to the gastric juice, which, having been secreted 
before death, and collected in the stomach, may, once that life 
has ceased, dissolve the parietes of the stomach, just as, during 
life, it dissolved only the organized, though not living substan- 
ces, contained in that viscus 1* M. Camerer mentions on this 
head a very remarkable experiment, which, if it does not prove 
the action of the gastric juice on the parietes of the stomach, 
proves at least that certain fluids contained in softened stom- 
achs may produce softening in other stomachs when introduced 
into them. A fluid collected in the stomachs of two children 
that had died of a gelatiniform softening of that viscus was in- 
troduced in the dose of a drachm into the stomach of a man 
not long dead, which was then kept for twelve hours in a moist 
heat of 20° R. (77° F.). At the end of that period, the mem- 
branes of the stomach were found dissolved through to the pe- 
ritoneum wherever the fluid had been in contact with them. 
The same fluid was introduced into the stomach of a living rab- 



* Vid. page 20. 



64 DISEASES OF THE ALIMENTARY CANAL 

bit, without producing any bad effect ; and on the animal's being 
killed its stomach was found in the most healthy condition. 
On the contrary, another portion of the same fluid having been 
deposited in the stomach of the rabbit, after death, its parietes 
exhibited a pultaceous softening after a certain period. Now 
if, during life, the nerves distributed to the stomach from the 
pneumo-gastric and trisplanchnic be cut on each side, and the 
same fluid be then introduced into the stomach of the animals 
thus treated, their stomach softens ; but this effect does not en- 
sue if the nerves be cut without applying the fluid. 

Several of these facts appear to me to prove clearly that 
softening of the stomach should be reckoned as one of the al- 
terations which may take place after death in certain cases. 
There may have been in the stomach during life a morbid af- 
fection of such a nature, as to discover itself to us after death 
by the softening of the stomach, as it did before that period, by 
certain well marked functional derangements ; since it may 
have produced such a state of the stomech as to render it ca- 
pable of softening after death under the influence of causes, 
which would otherwise have been either not called into action, 
or else inadequate to produce that effect. 

As to the cause that produces softening of the alimentary 
canal during life, it is far from being evident in every instance. 
That it may have been an acute or chronic process of irritation 
is undeniable ; for it is very plain that such is the case when 
the gastric mucous membrane, for instance, is found softened 
in persons who have swallowed a corrosive poison. But here, 
again, as in all other cases, irritation effects this only by pro- 
ducing in the natural mode of nutrition a derangement which 
subsequently gives rise to softening or to induration, according 
to the individual in whom it occurs. But, in many cases, it is 
only by hypothesis we can admit that a stomach that is found 
softened has been in a state of irritation. For, how is its exist- 
ence to be proved ? Is it from the nature of the external agents 
which may have been able to affect the patient ? The existence 
of such agents cannot always be proved, and their mode of ac- 
tion is not always easily determined. Thus, the gelatiniform 
softening of the stomach so well described by M. Cruveilhier, 



BELOW THE DIAPHRAGM. 65 

has been observed by him to occur chiefly in children that 
were recently weaned, and badly fed ; and some have not hesi- 
tated to conclude that the weaning and unwholesome food had 
been the causes of irritation to the stomach : but that is only 
one side of the question, and we have just as much reason to 
assert that the softening of the stomach occurred, not because 
it was exposed to the contact of irritating substances but because 
the alimentary principles, being either insufficient, or unsuitable 
to the nutritive action of the organs, had deranged the nutrition 
of each in general, and of the stomach in particular. In the same 
manner, might we add, the transparent cornea becomes soft 
in animals that are kept on food not sufficiently nutritive. Let 
not any one, then, imagine that he has quite settled the ques- 
tion by saying that the premature weaning, for instance, softens 
the stomach only by irritating it. If he attempts to prove the 
existence of irritation by pathological anatomy, I answer, what 
part can shew it less than certain stomachs whose parietes are 
completely devoid of colour, and exhibit no change but a dimi- 
nution of consistence ? Lastly, if he attempts to prove its ex- 
istence by the nature of the symptoms that made their appear- 
ance, I repeat an observation that I have already made, that, 
of the numerous symptoms which may arise from an affection 
of an organ, all may serve to indicate the seat of that affection, 
but very few are capable of discovering its nature. Now, 
those which most frequently accompany softening of the stom- 
ach are, anorexia, a sensation of weight in the epigastrium, and 
difficulty of digestion ; and can any single one of them be con- 
sidered as necessarily produced by irritation ? 

We must acknowledge, then, that, in the present state of the 
science, softening of the parietes of the alimentary canal ap- 
pears to be often connected with a process of irritation ; but 
that the existence of such a process is not sufficient to produce 
it, and that, consequently, it is neither the sole, nor the neces- 
sary cause of it. 



Vol. II. 10 



66 DISEASES OF THE ALIMENTARY CANAL 



§ IV. Ulceration of the Alimentary Canal. 



The portion of the alimentary canal at present under consid- 
eration is one of the parts of the body in which ulceration has 
most frequently been observed to exist ; but all parts of it are 
not equally subject to the affection. With respect to the fre- 
quency of its occurrence, they may be arranged in the follow- 
ing manner : — 

1. The ileum in its inferior two-fifths. 

2. The cascum. 

3. The colon. 

4. The rectum. 

5. The ileum in its superior three-fifths. 

6. The stomach. 

7. The jejunum. 

8. The duodenum. 

Ulceration of these different parts may be preceded by va- 
rious lesions, especially the following. 

1. The ulcers may be formed in the centre of small red spots, 
in the intervals between which the mucous membrane is free 
from alteration. These spots are merely the result of a more 
or less strong injection of the mucous membrane. There is no 
proof of the existence of any follicles where they make their 
appearance. 

2. In place of red spots thus isolated, the internal surface of 
the alimentary canal may, for a certain extent, exhibit a diffused 
redness, in the midst of which ulcers appear here and there in 
greater or less number. In this case, as in the preceding, 
there is nothing to prove that the ulcers have their origin in 
.follicles. 

3. In some cases, instead of being simply injected, the 
ulcerated portion of the mucous membrane is more or less con- 
siderably softened. 

4. The ulcers are often preceded by a preternatural devel- 
opement of the follicles, and are then formed in them. This 



BELOW THE DIAPHRAGM. 



67 



may occur both in the isolated follicles, and in the aggregated 
ones known by the name of Peyer's gland. 

The isolated follicles of the alimentary canal, before becom- 
ing ulcerated, generally begin by increasing in size: they be- 
come gorged and tumid, and appear on the internal surface 
of the intestines like conical knobs of a red or greyish colour. 
Sometimes they are but few in number, and sometimes they 
are in a manner confluent, and cover a great part of the inter- 
nal surface of the small and great intestine. In a longer or 
shorter time after this, they lose their conical form, and a slight 
depression appears on their summit, which, though sometimes 
owing to an enlargement of the orifice of the follicle, is more 
frequently produced by an incipient ulcer. This depression 
gradually becomes more considerable; and, at a particular 
stage of this process, the knobs may, in form, be fairly enough 
compared to the dimpled pustules of small pox. At a still later 
period, the pimple disappears, being gradually destroyed from 
its summit to its base; and in its place is found a circular ulcer, 
which either remains isolated, or, as it increases, tends to run 
into the neighbouring ulcers. 

It is not only in the acute state that ulceration is observed 
to succeed obstruction of the intestinal follicles: it occurs like- 
wise in the chronic state. Thus, after some of them have long 
remained distended by a matter of a tuberculous appearance 
that makes them resemble small granules of a dead white col- 
our, we at last observe the process of morbid secretion which 
had been previously going on in the follicle, to be succeeded by 
a process of ulceration. 

Very often, too, the aggregated follicles at the end of the 
small intestine, and in the caecum, which constitute the glands 
of Peyer, become the seat of ulcers remarkable for their form 
and situation. Like the isolated follicles, they begin by grow- 
ing more apparent, and form on the internal surface of the in- 
testine, on the side opposite the insertion of the mesentery, 
large oblong patches, of a grey, brown, or red colour, which 
rise above the level of the mucous membrane, and often ex- 
tend several inches in length. On these patches are sometimes 
observed a few solutions of continuity, of a circular or irregular 



68 DISEASES OF THE ALIMENTARY CANAL 

form, of small extent, and far asunder. These very superficial 
ulcers gradually extend both in depth and surface; at last they 
run into another, and then, instead of a patch elevated above 
the mucous membrane, there appears an ulcer, which is oblong 
like the group of follicles it has replaced, extends, like them, 
several inches in length, and, like them, occupies the free side 
of the intestine. Such is most usually the origin of those ulcers 
so frequently met with in the lower fifth of the small intestine, 
and in the caecum, after severe fevers. 

5. In some cases, which however are much rarer than was 
long supposed, the ulceration of the mucous membrane does 
not take place until after it has been struck with gangrene ; and 
the solution of continuity then succeeds the sloughing. This 
cause of ulceration is very uncommon, and I recollect but very 
few instances of it. In two of them, a fragment of mucous 
membrane, of a blackish grey colour, and gangrenous fetor, 
was attached to the rest of the membrane merely by a kind of 
narrow appendage, and beneath it was an ulcer. 

6. In all the preceding cases, the different lesions we have 
seen preceding ulceration existed in the mucous membrane it- 
self; at other times, it happens that the original lesion, which 
is subsequently to give rise to the ulceration, is not situated in 
that membrane. This is what is observed to occur, when cer- 
tain morbid secretions, especially tuberculous matter, take place 
in the submucous cellular tissue. The mucous membrane, be- 
ing irritated by the presence of this matter, becomes congested, 
and ulcerates like the bronchial mucous membrane, in order to 
give exit to the tuberculous matter formed without the cavity 
it lines. It is asserted that such is the origin of those ulcers 
that are so frequently found in the intestines of phthisical per- 
sons: this may be the case in some instances, but is not con- 
stantly so; and in many such persons whose intestines were al- 
most riddled with ulcers, I found nothing to prove that they 
had originated in tubercles beneath the mucous membrane. 

In every part of the alimentary canal, ulceration may result 
from acute as well as from chronic irritation. In this respect, 
however, there is a remarkable difference to be observed be- 
tween the stomach and the intestines properly so called. In 



BELOW THE DIAPHRAGM. 



69 



the stomach, ulceration is very rarely produced by acute irrita- 
tion ; it scarcely ever occurs there but after a chronic irritation 
of long continuance. In both the small and the great intestine, 
it is frequently produced by chronic irritation, as in the stom- 
ach; but, besides, it very often results from acute. 

With respect to their number, size, form, and direction, in- 
testinal ulcers present the following peculiarities. 

Their number is very variable. In some cases, there is but 
a single ulcer in the whole extent of the canal ; in others, a 
great portion of intestine is absolutely riddled with them. When 
they occur in the stomach, they are generally but few in num- 
ber. At the end of the small intestine, they sometimes appear 
crowded together for an extent of from one and a half to two 
feet. Lastly, we occasionally find the whole internal surface 
of the great intestine completely riddled with an immense num- 
ber of ulcers, which often resemble one another in form and 
size. They are generally smaller than those of the end of the 
small intestine, as well as of a circular form, whilst the others 
are more frequently ovalish. I lately saw a case, where, from 
the end of the rectum to the ascending portion of the colon, 
there was not a space of a few lines in succession which was 
not occupied by ulcers resembling each other with respect, both 
to form, which was exactly circular in all, and to size, which 
was that of a five sous piece. 

The forms of the ulcers may generally be reduced to the 
following. 

1. The circular form. This is often so regular, that the 
ulcers appear as if made with a punch ; and exhibit a strictly 
geometrical circle. 

2. The ovalish form. This appears particularly in the ulcers 
situated in Peyer's glands. 

3. The linear form. The ulcer here appears as a narrow 
groove, which resembles a geometrical straight or curved line. 

4. The irregular form. This cannot be compared to any 
geometrical figure ; and, what one would not suppose a priori, 
is the least frequent of all. 

The great diameter of the ulcers may be either parallel, per- 
pendicular, or oblique, to the axis of the intestine. They are in 



70 DISEASES OF THE ALIMENTARY CANAL 

general confined to one side of the intestine ; but sometimes 
they occupy its whole circumference. I recollect having seen 
a case in which the internal surface of the small intestine ex- 
hibited, at intervals, large ulcers, each of which formed, like the 
portion of intestine it occupied, a perfect ring. There were a 
dozen such, all disposed in the same manner. 

Ulcers of the alimentary canal, like every other solution 
of continuity, are to be considered as to their margin and their 
bottom. 

The margin of each is formed by the mucous membrane, 
which may present various appearances. Thus, with respect 
to colour, the margin of the ulcer is sometimes perfectly white, 
and sometimes red, or of a more or less deep brown. More- 
over, the portion of membrane that forms it may be, 1. in its 
natural state as to thickness and consistence ; or, 2. it may be 
softer or harder, thicker or thinner, than natural. In some ul- 
cers of long standing, the margin exhibits remarkable alterations 
of nutrition in the component tissues. Beneath the more or 
less thickened mucous membrane which forms it, appears a 
layer of cellular tissue which is also thickened, and indurated. 
From the margin of the ulcer prolongations are sometimes de- 
tached, which either terminate in a free extremity, that floats 
above the bottom of the ulcer, or shoot over and adhere to the 
opposite side, forming a kind of arch or bridge over it. In some 
cases, cicatrization takes place beneath these, which then re- 
main as traces of the chronic ulcer that had formerly existed 
there. 

The bottom of the ulcers may consist of different tissues, 
and present various appearances which it is important to ob- 
serve. 

In the first place, there are found, both in the stomach and 
small intestine, very superficial ulcers, which might be better 
termed simple erosions, and at whose bottom the mucous mem- 
brane still remains. However, an evident depression is observ- 
able where they exist, and there has been undoubtedly a loss 
of substance : but it is not the texture of the membrane itself 
that has been destroyed ; it is only the villi. From their defi- 
ciency, in a circumscribed space, results that depression which 



BELOW THE DIAPHRAGM. 71 

at first gives the impression of the existence of a complete 
solution of continuity of the whole substance of the mucous 
membrane. 

The case I have just described is not very uncommon, but 
is much less frequent than that where there is no longer any 
trace of the mucous membrane; we then have a complete ul- 
cer, whose bottom may consist of some one or other of the 
subjacent tissues. Thus, it very often consists of the submucous 
cellular tissue, which may be altered, either in colour, consist- 
ence, or thickness. For instance, it is found to be red, grey, 
brown, or deep black; soft, and as it were fungous, or hard and 
scirrhous, according to the case. At other times, on the con- 
trary, the cellular tissue which forms the bottom of the ulcer 
retains all its natural qualities ; the bottom is then white, while 
the margin is often equally so. It is not unusual to find in the 
alimentary canal a great number of such ulcers, which present 
no other alteration than the solution of continuity which forms 
them. They are often found in children who have been ex- 
hausted by chronic' diarrhoea, and, after the complaint has be- 
come less severe, or even ceased altogether, have died either 
in a state of coma, or in convulsions ; their death thus com- 
mencing at the brain. They are also found in adults who die 
during their convalescence from gastro-intestinal inflammation. 

Instead of the submucous cellular tissue, the bottom of the 
ulcer may be found to be formed by the muscular layer, wheth- 
er in the sound state, or altered with respect to colour and con- 
sistence. There are cases where the bottoms of all the ulcers 
in the same subject consist of this fleshy coat. I lately saw a 
remarkable instance of this in a woman who died at La 
Charite, in a state of great exhaustion, of a diarrhoea of about 
three weeks' continuance. For an extent of from two and a 
half to three feet above the ileo-csecal valve, the internal sur- 
face of the ileum was overspread with large ulcers, of which 
many, that were of an ovalish form, were seated in Peyer's 
glands. At the bottom of all the ulcers appeared the bare 
muscular coat, with its circular fibres perfectly marked : it did 
not present any alteration ; and what was very remarkable, 
neither the margin nor the bottom of the ulcers exhibited the 



72 DISEASES OF THE ALIMENTARY CANAL 

least appearance of injection ; the intervals between the ulcers 
were also free from it. 

Lastly, the muscular coat itself may be destroyed, and the 
bottom of the ulcers consist only of the peritoneal membrane, 
either transparent and thin as in the natural condition, or cov- 
ered at the side of the cavity of the intestine by a layer of 
cellular tissue more or less altered, which is that naturally in- 
terposed between the muscular and serous coats. 

It is not without its use to know that the bottom of ulcers of 
the intestines may be formed of the different tissues we have 
just pointed out ; for, if we bear in mind that, instead of ex- 
tending simply in surface, and stopping at the submucous cel- 
lular tissue, the ulcers may extend also in depth, and destroy 
all the coats down to the peritoneum, we shall perceive that 
this likewise may easily be destroyed in its turn ; whence will 
arise a perforation. The probability of the occurrence of this 
is not to be estimated by the number or size of the ulcers, but 
solely by their tendency to increase in depth. Thus, we may 
find in the alimentary canal an immense number of ulcers, 
which have existed a very long time, without any perforation 
having occurred ; while at other times we find but a single 
ulcer of inconsiderable size, and the intestine perforated in 
that spot. 

It is not sufficient to be acquainted with the various forms of 
the ulcers themselves ; we must attend also to the different 
states that, may be observed in the mucous and other tissues in 
the intervals between them. Now, in the first place, there are 
cases where there is no appreciable lesion to be discovered in 
those intervals. The mucous membrane is white and of good 
consistence throughout, and the subjacent tissues are equally 
free from alteration : indeed I have often been struck with this 
complete discoloration of the intestinal tube, while its internal 
surface was covered with numerous ulcers. At other times 
the membrane around the ulcers, without being reddened, is 
found to be either softened, or studded with a great number of 
follicles more than usually apparent. It is pretty commonly 
found injected, but the injection is rarely very considerable, 
even in those cases where there is every reason to believe that 



BELOW THE DIAPHRAGM. 



73 



the process of ulceration was very acute ; so that it would be 
altogether inexact to admit, that there is any proportion be- 
tween the intensity of the hypersemia of the mucous mem- 
brane, and the facility with which ulcers are produced. In 
fact, on the one hand, a very strong injection often exists with- 
out ulceration ; and, on the other, we have just seen, the in- 
ternal surface of the intestine is frequently overspread with ul- 
cers, without appearing to have received more blood than 
usual ; indeed, so far from it, it is in such cases sometimes re- 
markable for its great paleness. 

The mucous membrane is not the only layer of the gastro- 
intestinal parietes that is found altered in the intervals between 
the ulcers. It happens pretty often, especially in the stomach, 
that the submucous cellular tissue thickens and indurates more 
or less extensively around a solution of continuity of the mu- 
cous membrane. The ulcer then appears as it were in the 
centre of the scirrhous mass, and thus seems to be the termina- 
tion of the lesion, whilst it has been its source. In such cases, 
the cellular tissue thickens around an ulcer of the mucous mem- 
brane, just as it thickens around an ulcer of the skin. The 
name of cancer, then, should either be applied to both these 
alterations, which differ only in situation, or else to neither. 

Are ulcers of the alimentary canal susceptible of cicatriza- 
tion? The best way to answer this question is by giving an ac- 
count of what has been observed in persons that died during 
convalescence, and in whose intestines were found ulcers in 
different states, from that in which they were still in full 
action, to that in which they were beginning to disappear. 

In a man who died on the fifty-third day of a severe disease, 
during the course of which there had been a copious diarrhoea 
which continued to the last moment, the other morbid symp- 
toms also becoming chronic, I found on the internal surface of 
the ileum and caecum several ulcers, with elevated margins, 
and brown, wrinkled bottoms. But, in a few, the bottoms 
were on a level with the margins, which were pale ; in some 
of these, the bottom consisted of the ordinary submucous cel- 
lular tissue ; in others, of an extremely delicate web, con- 
tinuous with the margin, and situated above the cellular layer. 
Vol. II. 11 



74 DISEASES OP THE ALIMENTARY CANAL 

This web seemed to be the commencement of the re-produc- 
tion of the mucous membrane. 

A woman was attacked with fever, with a brown dry tongue, 
diarrhoea, and delirium ; from which she recovered. When 
fully convalescent, in consequence of a surfeit, the fever and 
diarrhoea returned, great prostration of strength succeeded, 
and death ensued. On dissection, there were found, towards 
the end of the small intestine, 1. some greyish patches, of a 
somewhat oval form, and slightly elevated above the level of 
the internal surface of the intestine ; (these were Peyer's glands 
in a state of tumefaction ;) and, 2. in other parts where these 
glands usually exist, some spots, which were likewise nearly 
oval, but were evidently below the level of the surface, and 
consisted of a very soft, delicate, rose-coloured membrane, 
which when put in water appeared to be without villi, and re- 
sembled a portion of the bronchial mucous membrane. Some 
other scattered points were discovered to be also without villi, 
while just beside them they were very apparent. 

It seems, then, that in the two cases just mentioned, we 
have instances of the reproduction of the mucous membrane, 
which, under such circumstances, at first makes its appearance 
without villi, like that of an excretory duct. 

In another case, in a person who died a few months after 
having had a continued fever with copious diarrhoea, I found, 
about a foot above the ileo-csecal valve, a remarkable pucker- 
ing of the mucous membrane, which was at the same time of 
a brown colour : the exact resemblance between this and cer- 
tain cutaneous cicatrices, induces me to think that it also may 
have been the result of cicatrization. In the same person, 
Peyer's glands were very conspicuous, and the mucous mem- 
brane had lost its villi in some circumscribed spots. 

I have on three or four occasions found a puckering resem- 
bling that just described in the stomach of persons about whose 
previous diseases I was unfortunately unable to procure any 
information. In one of these, a slip of mucous membrane, 
about four or five lines in length, passed over the puckering, 
and adhered by its extremities to the surrounding portion of 
the membrane. 



BELOW THE 1HAPHEAGM. 75 

§ V. Perforations of the Alimentary Canal. 



Ulcers of the alimentary canal, having once reached the 
peritoneum, may destroy it also, and the result is a perforation 
of the parietes of the stomach or intestines. Indeed, the more 
or less rapid increase in depth of an ulcer is the most frequent 
cause of those complete solutions of continuity, by which an 
accidental communication is established between the interior 
and exterior of the canal. 

An ulcer may thus become a perforation in three cases. 

1. In persons who appear in good health, or who at least 
are but slightly indisposed. I shall mention but two cases 
illustrative of this, though I could easily bring forward many 
others* A middle aged man had for a long time experienced 
at intervals pretty severe pains in the epigastrium ; his diges- 
tion was rather difficult, but his health did not appear deranged 
in other respects. He was quite suddenly attacked with all 
the symptoms of a very acute peritonitis, and died in less than 
four-and-twenty hours. On opening the body, a sero-purulent 
effusion was found in the peritoneum, and near the middle of 
the body of the stomach was an ulcer of the breadth of a franc 
piece, with a blackish margin, in whose bottom, which con- 
sisted of the muscular coat, was a perforation, at most but 
large enough to admit of the passage of a lentil ; its margin 
was formed by the torn peritoneum. There was no other 
lesion in the stomach, nor in the rest of the canal. 

I have already mentioned in my Clinique Medicate the case 
of a young man who, having been taken in at La Charite in- a 
slightly feverish state, without any symptom of importance, 
was suddenly attacked with peritonitis, which put an end to his 
life in a few hours. There was found in the intestine an ulcer, 
which had perforated it. 

2. We more frequently observe a perforation occurring in 
the centre of an ulcer, in that dangerous disease to which 
M. Bretonneau has lately given the name of dothinenteritis, in 



76 DISEASES OF THE ALIMENTARY CANAL 

which the internal surface of the small intestine is generally- 
overspread with ulcers. 

3. Lastly, we may also observe perforations occurring in 
persons in the last stage of a chronic affection of the stomach 
or intestines ; and here, again, their origin has been an ulcer. 
Thus it is that a peritonitis resulting from a perforation some- 
times puts an end to phthisical patients whose intestines con- 
tain numbers of ulcers. 

However, perforation of the stomach or intestines is not al- 
ways necessarily preceded by an ulcer. Thus, softening of the 
stomach, carried to a certain degree, may produce it without 
any previous ulceration. Besides, we must not forget that we 
might sometimes chance to consider as produced during life, a 
perforation that was caused at the time of opening the body by 
pulling or pressing on the softened stomach. 

Again, a slough involving the whole thickness of the gastro- 
intestinal parietes, may, when thrown off, produce perforation. 
This has been scarcely ever observed to occur but in two 
cases ; 1. in cases of poisoning by sulphuric acid ; and, 2. in 
strangulated hernia. 

Can the gastro-intestinal parietes be so distended with gases, 
under certain circumstances, as that perforation from mechan- 
ical rupture shall be the result ? This has been observed to 
occur in animals ; I am not aware that an instance of it has 
yet been observed in man. 

It is in the horse, too, that the stomach has chiefly been ob- 
served to burst and become perforated, in the midst of attempts 
to vomit artificially produced. The rupture has always been 
observed to take place towards the great curvature ; and it may 
be produced in the same situation, by pressing strongly on a 
stomach previously distended by fluids or gases. Now, it is 
known, that the horse cannot expel the contents of its stomach, 
without extreme difficulty, and the strongest exertions ; and the 
powerful pressure exerted by the abdominal muscles on the 
distended stomach, under such circumstances, must contribute 
still more strongly than the contraction of its own muscles, to 
rupture its parietes. I do not know whether there has been 
an instance observed in the human subject of the bursting of a 



BELOW THE DIAPHRAGM. 



77 



sound stomach in the attempt to expel its contents ; but it has 
been known to be ruptured, on the same occasion, in persons 
who had been long affected with a more or less considerable 
disorganization of its parietes. A man who had all the appear- 
ance of a so called cancerous affection of the stomach, took 
two grains of tartar emetic ; in the midst of an effort to vomit 
he was seized with severe pain in the abdomen, and died in a 
few hours afterwards. On opening the body, there were found, 
1. a peritonitis ; 2. a perforation of the parietes of the stomach ; 
and, 3. around the perforation, traces of a chronic ulcer of the 
mucous membrane, together with great alteration in the tex- 
ture of the subjacent tissues. 

M. Bouillaud records a case of a person whose stomach, 
which had long been diseased, burst while he was straining at 
stool. In this case, the rupture was caused chiefly by the 
pressure of the abdominal muscles. The perforation occurred 
at one extremity of an extensive ulcer, the bottom of which 
was formed by the pancreas.* 

It has been asserted that worms of the species ascaris lum- 
bricoides sometimes perforate the parietes of the intestines. I 
am not acquainted with any fact to prove the truth of this 
opinion ; and in some cases in which worms have been ob- 
served coming out of a perforation, it is to be presumed they 
merely passed through an opening which they found ready 
made. 

Among the causes of perforations of the alimentary canal 
must be reckoned external violence applied to some some part 
of the abdominal parietes. Thus, in the Bulletins ale la Faculte 
de Medicine de Paris, (vol. i.) we have an account of a com- 
plete solution of continuity of the intestine, near the union of 
the colon and rectum, produced by the passage of a wheel over 
the loins : there was no bone fractured. M. Marjolinf has 
given us another case of a complete rupture of the small intes- 
tine, which was likewise occasioned by a contusion on the ab- 
domen. The skin of the part was uninjured, but the abdomi- 



* Archives de Medicine, vol. i. pag. 534. ] Archives de Medicine, vol. ii. 



78 DISEASES OF THE ALIMENTARY CANAL 

nal muscles were torn, and at about eighteen inches from the 
duodenum the small intestine was completely cut across. 

In the various cases we have considered, the causes which 
produce the perforation of the gastro-intestinal parietes are 
manifest, and their manner of acting is easily explained. But 
what explanation are we to offer, when the stomach and intes- 
tines become suddenly perforated in the midst of a very good 
state of health ? What are those perforations that are denom- 
inated by authors spontaneous ? That term was adopted at a 
time when it was thought that every perforation of the gastro- 
intestinal parietes was the result of poisoning with corrosive 
substances. Some cases were observed in which perforations 
had occurred without the intervention of any external cause to 
account for them, and they were consequently termed sponta- 
neous. If we read over again the observations that were pub- 
lished on this kind of perforation, we shall find that they may 
be ranged in two classes. Some of them relate to cases in 
which, before the occurrence of the perforation, there had 
been more or less strongly marked signs of an acute or chronic 
affection of some part of the alimentary canal; while on open- 
ing the body the perforation was found in or near membranes 
that were ulcerated, softened, or in short, altered in some way 
or other. In others, there is nothing of the kind : individuals 
in perfect health are suddenly attacked with very severe pain 
in the abdomen ; they die in a few hours ; and, on opening the 
body an effusion is found in the peritoneum, and a perforation 
in some part of the parietes of the stomach, without any other 
lesion of that viscus, except, in a few instances, a pulpy soften- 
ing around the perforation. Are we to say with Hunter and 
many modern pathologists, that such a perforation may be 
owing to the corrosive quality the gastric juice can sometimes 
acquire, by virtue of which it in a manner dissolves the parietes 
of the stomach ? This hypothesis has already been discussed. 
Shall we, then, say that it is the result of a process of irritation^ 
that has become suddenly developed in some part of the canal ? 
But, that is just as much an hypothesis as the supposition of 
Hunter. 



BELOW THE DIAPHRAGM. 



79 



We must acknowledge, then, that there are some perfora- 
tions the cause of which is far from being yet perfectly known 
to us. Be it what it may, an important question presents it- 
self: are there any certain anatomical characters, by means of 
which a so called spontaneous perforation may be distinguished 
from one which is owing to the action of a poison ? And, are 
such characters to be found in the form of the perforation it- 
self? I think not; for I have seen the perforation affect the 
same varieties of form (sometimes the circular, with a smooth 
margin, and sometimes the irregular, with a fringed or torn 
margin, presenting shreds of various membranes.) both in men 
in whom it was not produced by poison, and in animals in 
which it was. Shall we then draw these distinctive charac- 
ters from the appearance of the parts surrounding the perfora- 
tion ? They are not at all more certain ; for whether there has 
been poison in the case or not, the surrounding parts are alike 
red, disorganized, softened, and gangrened. Lastly, traces of 
violent irritation may be found in the rest of the stomach, in 
both cases equally. When, however, there are numbers of 
sloughs in several spots in the stomach, there is strong ground 
to suspect the presence of poison, because such sloughs are but 
very seldom observed in any other case. When, on the con- 
trary, there is no other lesion observed in the stomach but the 
perforation itself, the probability is that there has not been any 
poisoning ; for it is not easy to conceive how a corrosive sub- 
stance introduced into the stomach, could act but upon one 
point precisely. The thing would not, however, be absolutely 
impossible. It follows from this discussion, that anatomical 
examination, while it often furnishes no useful information to 
enable us to distinguish a so called spontaneous perforation, 
from a perforation from poison, sometimes affords a greater or 
less degree of probability, but never perfect certainty. 

Peforations do not occur with equal frequency in all parts of 
the alimentary canal; they are more common in the stomach 
than any where else, especially in its splenic portion. In the 
rest of the alimentary canal, they are seldom observed except 
at the bottom of ulcers ; while, in the stomach they are much 
less frequently preceded by ulceration. Lastly, in some cases 



80 DISEASES OF THE ALIMENTARY CANAL 

several perforations have been found existing simultaneously 
in the same intestinal tube. 

No age is exempt from this affection. It has been observed 
in children scarcely a few days or weeks eld. M. Cruveilhier 
has more than once found the stomach perforated towards its 
great extremity, in children that had been affected with a gelat- 
iniform softening of that viscus. 

It would result from some cases, that it should be reckoned 
among the serious lesions to which women are liable shortly 
after delivery. Instances of it have also been noticed in persons 
who had recently undergone severe operations. 

I have hitherto supposed every perforation of the gastroin- 
testinal parietes to take place during life. It has, however, 
been made a question whether many perforations of the stom- 
ach did not occur after death ; and this ought to be at least 
discussed by those who think that some softenings of the stom- 
ach do not occur till after death also. 

I have already considered the cases in which it has been 
thought reasonable to conclude that perforations of the stom- 
ach may take place after death ; and do not intend returning 
to that subject at present. I shall merely observe that the 
cases in which the occurrence of this kind of perforation has 
been admitted, because both the stomach and diaphragm were 
found at the same time softened and perforated, do not prove 
that it was the fluid that escaped from the perforated stomach 
which exerted a kind of solvent action on the diaphragm ; for, 
in other cases, both diaphragm and stomach have been found 
as much softened, without the latter being perforated. Thus, 
Jaeger has mentioned a case in which, at the same time that 
the parietes of the great extremity of the stomach presented a 
gelatiniform softening, and could be torn with the greatest 
ease by the slightest pull, the softening had extended to the 
lower third of the oesophagus, and one of the halves of the dia- 
phragm. The individual in whom this was observed was a 
child a year and a half old, who had presented the symptoms 
of acute hydrocephalus : in the same subject, the membranes 
of the brain were strongly injected, and there was some serum 
in the ventricles. 



BELOW THE DIAPHRAGM. 



81 



Perforations of the gastro-intestinal parietes may establish 
various kinds of communication between the exterior and inte- 
rior of the stomach or intestines. 

1. The most usual communication is that formed between 
the cavity of the alimentary canal and that of the peritoneum. 
In such cases that membrane becomes the seat of violent irri- 
tation, and in a very short time the patient dies in great pain, 
with all the symptoms of the disease known by the name of 
acute peritonitis. This is what generally happens '; but some- 
times the contents of the canal escape into the peritoneum 
without producing any such effects, and give rise only to an 
obscure lingering irritation, with feebly marked symptoms, and 
obtuse pain. I shall never forget the case of a young phthis- 
ical patient, from whom an ascaris lumbricoides came away 
one day by the navel. He lived for some weeks afterwards ; 
and every day a small quantity of a matter resembling that 
usually contained in the intestines, escaped by the umbilical 
orifice, which remained fistulous. On opening the body it was 
found that there had been chronic peritonitis, which had given 
rise to the formation of numbers of false membranes, among 
which floated several other ascarides through a fluid remark- 
able for its dirty grey colour and fetid smell ; this was the in- 
testinal matter which escaped every day through the fistula. 
Thus, we have an instance of fecal matter and worms escaping 
from the intestines, and continuing in the peritoneum, without 
producing any thing but a chronic peritonitis. 

2. It sometimes happens that the cavity of the alimentary 
canal, instead of communicating by perforation with the cavity 
of the peritoneum, communicates with the cellular tissue out- 
side that membrane ; this has frequently been observed in cases 
of perforation of the rectum. 

3. The perforation may make a communication between the 
alimentary canal and the surface of the body ; the perforated 
point then forms the internal orifice of a fistulous passage of 
which the external is the perforation of the skin. The stom- 
ach, small intestine, cascum, and colon, have been observed to 
communicate thus directly with the exterior. Many of these 
accidental communications form what is called an artificial 

Vol. II. 12 



82 DISEASES OF THE ALIMENTARY CANAL 

anus ; and when a similar communication is established be- 
tween the lower part of the rectum and the exterior, by means 
of a perforation in its parietes, there results what is called a fis- 
tula in ano. 

4. In some particular cases, when a perforation is formed in 
some point of the gastro-intestinal parietes, no escape takes 
place into the peritoneum, because adhesion had previously 
been established between the intestine and some neighbouring 
part, which itself subsequently presents various alterations, ac- 
cording to its nature and the lesions it may have undergone. 

Most of the abdominal viscera have in this manner served 
more or less frequently to supply the place of that portion of 
the gastro-intestinal parietes which had suffered the solution of 
continuity, and have thus prevented any escape. Often, for 
instance, when the parietes of the stomach have been com- 
pletely destroyed for a certain extent, their place is supplied 
either by the parietes of the transverse colon, or by the dia- 
phragm, liver, spleen, or pancreas. All these cases have been 
observed, and in all were found cellular adhesions closely uni- 
ting the circumference of the perforation with the organ which 
stopped it up. 

M. Rayer saw a perforation of the duodenum likewise stop- 
ped up by the liver. In this instance the gall bladder was also 
destroyed. The patient died of a dreadful haemorrhage, which 
was found to proceed from a considerable branch of the vena 
portae, that opened into the bottom of the ulcer. 

I once found a vast ulcer in the ascending colon, the bottom 
of which was formed by the substance of the kidney. 

If the organs that stop up the perforation have themselves a 
cavity, their own parietes may in their turn be perforated, and 
a communication is then established between two natural cavi- 
ties. In this manner the interior of the rectum is often found 
communicating with the interior of the bladder, uterus, or va- 
gina. Sometimes, also, two portions of intestine that have 
been united by old adhesions, become perforated, and commu- 
nicate together. One of the most remarkable cases of this kind 
that have been observed, is that mentioned by M. Chomel, in 
which the duodenum communicated with the colon through the 



BELOW THE DIAPHRAGM. 83 

gall bladder, which adhered to both, and was itself likewise 
perforated. Another, equally interesting case, of an accidental 
communication between two coils of the ileum, has been re- 
corded in the third volume of the Bulletins de la Faculte de 
Medecine. It was observed in an old man of seventy, who 
died of acute pneumonia. The various parts of the intestinal 
tube were found adhering to each other by cellular frsena, the 
remains of an old peritonitis. Between two coils of intestine, in 
the midst of the uniting frsena, was a small canal three lines 
long, and eight wide, which established a free communication 
between them. Its internal surface was lined with a mucous 
membrane, which was continuous with that of the intestines. 

Lastly, not only does the diaphragm often serve as a bottom 
to ulcers of the stomach, but it may itself be perforated also ; 
and a communication is then established between the cavity of 
the stomach and the interior of the thoracic cavity. I have al- 
ready mentioned some cases of this description. 

Hitherto we have seen the perforations of the gastro-intestinal 
parietes taking place from within outwards ; the process of de- 
struction commencing with the mucous, and ending with the 
serous membrane. But, the contrary may also occur : when a 
collection of purulent matter has formed in the neighbourhood 
of the alimentary canal, this latter is one of the passages by 
which the pus sometimes makes its way out. Although, in my 
opinion, the frequency of abcesses of the liver opening into the 
stomach has been exaggerated, there is yet no denying that, in 
some cases, of as rare occurrence as hepatic abscess itself is, the 
contents of those abscesses have been thus evacuated. M.Cayol 
saw a case in which the ascending colon communicated by 
a narrow opening with a vast abscess in the substance of the 
right kidney, to which it was united by a cellular tissue remark- 
able for its great density, and slate-coloured tint.* Abscesses 
of considerable size, that were formed between the uterus and 
rectum, have been known to open and empty themselves into 
that intestine ; in one case of this kind,t there was felt during 



* Journal de Midecine, by Corvisart, Boyer, and Leroux ; vol. xiv. 
f Ibid. vol. xvii. 



84 DISEASES OF THE ALIMENTARY CANAL. 

life, behind the cervix uteri, a tumour whose nature was very 
difficult to determine, which might have been taken for an ob- 
struction of the uterus. Lastly, cases of peritoneal effusions 
have been recorded, which were evacuated through a perfora- 
tion of the parietes of the intestines. 



§ VI. Changes of Capacity in the Alimentary Canal, subse- 
quently to various Lesions of Nutrition. 



Increase of capacity in the alimentary canal has been chiefly 
observed in the stomach ; in which situation it has already been 
treated of. We have seen that that organ may become large 
enough to occupy the greatest part of the abdominal cavity ; in 
which case its parietes are rarely thickened, often of the natural 
thickness, and sometimes more or less attenuated. This in- 
crease of capacity is mostly accompanied by a contraction of 
the pyloric orifice ; in other cases it is found of the usual size ; 
and, lastly, in others, is remarkably enlarged. In these last, 
the parietes of the pyloric extremity are sometimes in their 
natural condition, and sometimes altered ; and the lesion af- 
fects particularly the muscular coat, of which there are only 
some scattered remains to be found, its place being occupied 
by a mass of indurated cellular tissue. 

Other portions of the alimentary canal are equally suscepti- 
ble of acquiring an unusual degree of capacity, when an ob- 
stacle to the passage of its contents has long existed in certain 
parts of it. Thus, I found the duodenum almost as voluminous 
as the stomach in its pyloric extremity, in an individual in 
whom the commencement of the ileum was obstructed by a 
tumour which scarcely permitted any thing to pass. 

The capacity of the stomach is often found diminished in cer- 
tain cases of scirrhous thickening of its parietes. It has also 
been found very small, indeed almost reduced to the dimen- 
sions of the intestine, in cases of poisoning by irritating sub- 
stances. However, diminution of capacity of the stomach is 
far from constantly accompanying all the shades of irritation 



BELOW THE DIAPHRAGM. 85 

which so often affect that viscus ; so far, indeed, that the stom- 
ach is frequently found rather dilated than contracted, in many 
cases in which it has been the seat of an evident process of 
irritation, acute or chronic. 

Whenever a portion of intestine has long ceased to receive 
the matter transmitted from the stomach, its parietes contract, 
and its cavity tends to become effaced. Thus, when these 
matters pass out altogether by an artificial anus, the portion of 
intestine below it has a very small cavity, whose parietes are as 
it were agglutinated by a little mucus. 

It has been asserted that, in the Colica Pictonum, the intes- 
tines are so strongly contracted as to present a much smaller 
cavity than natural. I think I may affirm, from my own ex- 
perience, that this assertion is by no means founded on truth. 

Lastly, there are cases in which the canal, instead of being 
simply contracted, appears in certain parts as a solid cord, 
without any trace of cavity ; but this very unnatural condition, 
which has scarcely ever been observed except in the great in- 
testine, belongs chiefly to congenital malformations, and will 
come under consideration farther on. 

The intestinal tube, instead of being contracted or oblitera- 
ted for a certain extent, may have its cavity more or less com- 
pletely effaced in a circumscribed point ; its contents can then 
no longer pass that point, and the same symptoms result as 
those which indicate to surgeons the existence of a strangulated 
hernia. 

The causes that may produce this obliteration of the cavity 
of the intestine are many, and shall now be enumerated. 



86 DISEASES OF THE ALIMENTARY CANAL 

FIRST ORDER OF CAUSES. 

Obstacles situated in the strangulated Portion of Intestine. 

FIRST GENUS. 



Obliteration from Alteration of Nutrition of the Intestinal 
Parietes. 

The parietes of the intestine may, by thickening, produce 
obliteration of its cavity in some particular point: the same ef- 
fect may be produced by a vegetation growing on the internal 
surface of the mucous membrane. 



SECOND GENUS. 



Obliteration from Substances contained i7i the Intestinal Cavity. 

A foreign body, a calculous concretion, an accumulation of 
fecal matter, or a bundle of worms, has often proved a com- 
plete obstacle to the course of the contents, and producing all 
the symptoms of strangulation. 



THIRD GENUS. 



Obliteration from unusual Contraction of the Muscular Coat. 

It sometimes happens that, on opening dead bodies, a large 
portion of the alimentary canal is found distended by a great 
quantity of gas up to a certain point where the intestine pre- 
sents an abrupt circular contraction, beyond which there is 



BELOW THE DIAPHRAGM. 



87 



neither gas, nor dilation of the cavity. At the spot where the 
narrowness exists, there is no appreciable organic lesion; it 
seems to be produced solely by a contraction of the muscular 
fibres, which has continued after death, just as that kind of 
muscular contraction which produces rigidity in the dead body 
does for a certain period. Now, did , this contraction of the 
intestine exist during life, or did it occur only at the moment of 
death? There are some patients that present a certain assem- 
blage of phenomena, which one would be inclined to explain 
by this spasmodic contraction, whether durable or transient, of 
a ring of the alimentary canal ; but we cannot affirm any thing 
positively on the subject. 

There is another kind of contraction sometimes presented by 
the muscular coat, in which a portion of intestine, quitting its 
natural situation, becomes inverted, and enters the adjacent 
portion. This produces what is called intussusception (or, 
more properly, introsusception) of the intestine, the meaning 
of the word being indicated by its etymology. An introsus- 
cepted intestine exactly resembles a finger of a glove the lower 
part of which has been thrust up into the upper. 

Many intestinal introsusceptions appear not to take place till 
the last moments ; and all who have observed the singular 
contractions that affect the alimentary canal of an animal at 
that period, will be surprised only that they are not more fre- 
quently met with in dead bodies. At the same time, it is be- 
yond all doubt, that introsusception may also occur a long time 
before death; for it sometimes forms a tumour which is per- 
ceptible during life through the abdominal parietes, and whose 
real nature is afterwards discovered by dissection. Be it as it 
may, in many cases in which an introsusception is discovered, 
no symptoms that could be referred to it have been observed 
during life. In others, on the contrary, whether on account of 
its bulk, or of its situation, it produces various bad effects, one 
of the principal of which is a real strangulation of the intestine. 
In every introsusception, the intestinal parietes are so dis- 
posed, that, as M. Dance* has very well explained, the mucous 

* Mtmoire sur les Invaginations morbides des Intestins. 



88 DISEASES OF THE ALIMENTARY CANAL 

membrane is innermost; next are two serous surfaces in con- 
tact with each other ; and, more externally still, are two mucous 
surfaces, also in contact. It is, as the accurate and learned 
author just quoted remarks, of importance to be acquainted 
with this circumstance ; since it can explain how, in conse- 
quence of the adhesions that must have a tendency to take 
place between the two serous surfaces in contact, the introsus- 
cepted portion of intestine has sometimes been detached, and 
passed by the anus, without any escape taking place into the 
peritoneum. 

Introsusceptions are most usually situated in the small intes- 
tine ; which is sufficiently accounted for by its extreme mobility. 
It is particularly in that situation they occur without producing 
any bad effects. The small intestine may itself be introsus- 
cepted into the caecum ; and there is nothing wonderful in that ; 
but, what one would not have imagined, which yet has been 
proved by observation, is, that the caecum and colon may be 
wholly introsuscepted into the sigmoid flexure of the latter, or 
into the rectum. 

Introsusceptions are very variable in their extent, as it 
amounts sometimes to but a few lines and sometimes to several 
feet. There have been cases in which the sigmoid flexure of 
the colon and the rectum were found to contain not only the 
rest of the great intestine, but also the most of the small, even 
as far as the duodenum. This is not all: the introsuscepted 
portion of intestine may protrude more or less considerably 
through the anus. Thus, Hevinus presented a preparation to 
the old Academie de Chirurgie, in which the caecum was to 
be seen entangled in the anus, outside which it formed a tu- 
mour. 

Introsusceptions of small extent, especially when situated in 
the small intestine, mostly produce no bad effects. At other 
times they give rise to certain morbid phenomena, resembling 
those that appear when the course of the contents of the ali- 
mentary canal is obstructed in any one point. In some cases, 
these symptoms are long before they become very severe, in- 
creasing in proportion as the introsusception itself increases; 
thus for several months, or even years, the individual suffers 



BELOW THE DIAPHRAGM. 89 

from nausea, vomiting, and more or less obstinate constipation. 
In others, the various symptoms that indicate intestinal stran- 
gulation appear suddenly in the midst of the most perfect state 
of health, and death speedily follows: this fatal termination 
does not, however, always occur; and sometimes it has hap- 
pened that, in consequence of the expulsion of the introsuscept- 
ed portion by the anus, the obstruction has ceased, and health 
has been re-established. 

Introsusceptions of considerable size often form more or less 
voluminous tumours in the abdominal parietes. In one of the 
cases related by M. Dance, in which the great intestine was 
introsuscepted into the sigmoid flexure of the colon, there was 
observed, on the one hand, a remarkable depression of the right 
iliac fossa, and, on the other, an elongated tumour in the left. 
In the same case, th& abdomen, when opened, presented a very 
singular appearance* there was at first no trace of the caecum, 
ascending colon, and right half of the transverse; the great in- 
testine did not commence till towards the end of the arch of 
the colon, and, for the length of eighteen or twenty inches pre- 
sented a great swelling as thick as the arm of an adult man, 
round, hard, resisting, and terminating abruptly near the end 
of the left iliac fossa, where the colon resumed its ordinary con- 
formation. 

The introsuscepted portion of the intestine is often struck 
with gangrene ; and sloughs are then thrown off, producing one 
or more perforations, through which the contents of the intes- 
tines escape into the peritoneum, and give rise to a new series 
of symptoms. 

But, one of the most remarkable phenomena presented by 
introsusceptions, is the complete separation of the introsuscept- 
ed portion, without any escape taking place into the perito- 
neum ; the detached portion passes out by the anus, and a per- 
fect cure follows. Hevinus saw two cases of this description ; 
one of the patients passed twenty-three inches of the colon, 
and the other twenty-eight of small intestine. The preparations 
were presented to the Academie de Chirurgie. M. Cruveilhier 
shewed the Societe de la Faculte de Medecine a coil of intestine 
eighteen inches long, with some of the mesentery adhering to 
Vol. II. 13 



90 DISEASES OP THE ALIMENTAItY CANAL 

it. It was passed by a man who for several days had had all 
the symptoms of strangulated hernia, which ceased as soon as 
it came away. I had an opportunity of examining a prepara- 
tion sent to the Acadhnie Regale de Medecine by MM. Bouniol 
and Riga] ; and ascertained it to be a portion of the small intes- 
tine, about thirty inches in length, with a small bit of the me- 
sentery adhering to it. The subject of the case had had an 
excessive surfeit after which he was seized with all the symp- 
toms that announce strangulation of the intestine ; he had be- 
sides in the right iliac region an uneven tumour, which was 
very sensible to the touch. At the end of twelve days he 
passed the portion of intestine and mesentery in question; upon 
which the symptoms disappeared, and he recovered, retaining 
only a feeling of pain in the right iliac region. In three months 
after, having eaten an enormous quantity of cherries, he was 
attacked with the symptoms of peritonhjs, and died. It is a 
pity the body was not examined; there would, probably, have 
been found a rupture of the cicatrice which must have been 
formed where the expelled portion of intestine had been de- 
tached. In other cases, however, there has been an opportu- 
nity of ascertaining the condition of the alimentary canal in 
persons who died in a longer or shorter time after having ex- 
pelled a portion of intestine by the rectum. A case of this 
kind is related by Hevinus; a man, who had all the symptoms 
that characterize internal strangulation, passed a long portion 
of intestine, composed of the whole of the caecum, six inches 
of the ileum, and six of the colon. Twelve days after this he 
died. On opening the body, the following appearances were 
observed: the caecum was wanting; the ileum opened into the 
colon, with which it was intimately united; at their point of 
junction was a narrow aperture which led to a collection of pus 
situated in front of the right kidney, and circumscribed on all 
sides by false membranes. Another fact of this kind is record- 
ed in the second volume of the Bulletins de la Societe Philoma- 
tique. It relates to a man who died forty-four days- after hav- 
ing passed by stool a portion of the small intestine sixteen 
inches in length. M. Dumeril saw the preparation. On ex- 
amination after death, the following peculiarities were discov- 



BELOW THE DIAPHRAGM. 91 

ered: "The two extremities of the intestine were perfectly 
united, and appeared as if their edges had been bevelled, and 
then fitted exactly to each other. They had contracted strong 
adhesions with the peritonem at their junction; nevertheless 
their cavity was not sensibly diminished, even at the cicatrice. 
The deficient portion belonged to the jejunum and ileum." 

Introsusception of the intestines has been observed at every 
age. Monro gives us a case of a child four months old, in whom 
the end of the ileum, the cascum, and the right half of the trans- 
verse colon, were found in the left half of the same. M. Cayol 
has related similar cases, in his translation of Scarpa's treatise 
on hernia. In one of those, the child, who was five months old, 
was suddenly affected with constipation and vomiting ; and a 
hard tumour, of the size of an egg, was discovered during life 
in the left iliac region ; six inches of the small intestine, and the 
whole of the colon, were found in the rectum. The other case 
mentioned by M. Cayol is remarkable for the introsusception 
being double : the ascending and transverse portions of the co- 
lon had in some sort retrograded towards their origin, and be- 
come introsuscepted into the caecum, which, in its turn, was 
introsuscepted, along with the contained mass of intestine, into, 
the descending portion of the colon. I do not know any in- 
stance but this of an inferior portion of great intestine being ta- 
ken up into a superior; in every other case that has been hith- 
erto recorded, the contrary was observed. In the small intes- 
tine likewise, the introsusception almost always takes place 
from above downwards. 



SECOND ORDER OF CAUSES. 



Obstacles situated without the strangulated Portion of Intestine. 

These obstacles may be owing to an irregular disposition, ei- 
ther of the peritoneum, or of the intestinal tube itself. 

The causes of strangulation proceeding from the peritoneum 
are the following : — 



92 DISEASES OF THE ALIMENTARY CANAL 

I. Perforation of the omentum. 

II. Perforation of the mesentery. 

III. Division of the omentum into several strips which ad- 
here to the abdominal parietes, and are liable to entangle some 
of the coils of intestine. 

IV. Accidental fraena extended like arches ; 

A. From one portion of intestine to another : 

B. From one portion of intestine to another organ ; thus, 
M.Esquirol saw a strangulation produced by a fraenum extending 
from the ligamenta lata of the uterus to the rectum. (It was a 
preparation presented to the Academie Royale de Medecine) 

C. From a portion of intestine to the abdominal parietes. 

D. From the omentum to another part of the abdomen. 

E. From one of the abdominal viscera to another. 

V. The mesentery being rolled up like a cord, and involving 
coils of intestine. 

The causes of strangulation proceeding from the intestinal 
tube itself are the following: — 

I. The compression of one portion of intestine by another. 
One of the most remarkable cases of this kind is that mentioned 
by Dr. Gendrin.* In a child six months old, who had from 
his birth suffered under habitual constipation, and continual 
vomitings, he found a portion of the transverse colon situated 
between the vertebral column and the duodenum, which con- 
fined it like a ligament. 

II. The perforation of a coil of intestine, and the escape of 
another coil, introsuscepted into the first, through the aperture 
so formed. In this case, the introsuscepted coil is strangulated 
by the margin of the perforation.! 

III. The unusual length of the appendiculum cseci, whereby 
it gets twisted around the ileum, and thus produces strangula- 
tion. 

IV. Preternatural adhesions of the free extremity of the ap- 
pendiculum, by which an arch or ring is formed, which readily 



+ Archives de Medecine, vol. viii. page 494. 

t Bulletins de la SocieU Medicate d 1 Emulation pour 1S22. Case by M. Martin 
Solon. 



BELOW THE DIAPHRAGM. 93 

produces strangulation if a portion of intestine gets entangled 
in it. 

V. The twisting of a diverticulum around a coil of intestine. 

VI. Adhesions of the free extremity of the diverticulum, 
which, then becoming an arch, may compress any portion of 
intestine that may happen to slip under it. However, it is not 
always the entangled portion of intestine that is strangulated ; 
it has sometimes been known to produce strangulation in anoth- 
er portion, which, by adhering to the free extremity of the di- 
verticulum, completes the ring of which this latter forms a seg- 
ment. 

The various causes of intestinal strangulation that have now 
been enumerated may occur suddenly or slowly. In the for- 
mer case, very serious affections, which rapidly prove fatal, 
make their appearance all at once, without any premonitory 
symptoms. In the latter, there are observed for a longer or 
shorter space of time, for months or even years, various symp- 
toms which are all connected with the existence of a greater or 
less obstacle to the free passage of the contents of the alimen- 
tary canal. 

Some of these causes do not necessarily produce strangula- 
tion. Thus, all the varieties of freena that have been described 
are found in dead bodies without such an effect having taken 
place; but then a single contractile movement of a coil of in- 
testine, made in a certain direction, would have been sufficient 
to cause it during life. 



§ Congenital Lesions of Nutrition. 



We are not yet acquainted with any case in which the infra- 
diaphragmatic portion of the alimentary canal was completely 
deficient ; there have always been some vestiges of it, whilst 
it has happened more than once that there has not been the 
least rudiment of the cerebro-spinal axis, or of the heart, to be 
found. These results of observation accord very well with 
those to which theory would lead us, and afford a confirmation 



94 DISEASES OP THE ALIMENTARY CANAL 

to the principle, that the parts first developed are those which 
are most rarely deficient ; it being now perfectly well known 
that the alimentary canal is partly formed, before there is any 
trace of spinal cord, brain, or heart, to be seen. Accordingly 
monsters have been seen that actually consisted only of a more 
or less perfect abdomen ; but there has never been an instance 
of a head or thorax being formed separately. Man, when im- 
perfectly developed, can thus stop at the point which consti- 
tutes the complete organization of certain animals, and present, 
like them, nothing but a simple digestive cavity. But, how- 
ever simple its organization, the zoophyte can live and multi- 
ply, being a natural creature ; whereas man, when similarly 
organized, cannot, because his continuing to exist in that rudi- 
mentary state would be contrary to the laws of nature. 

Of the different parts which, taken together, constitute the 
gastro-intestinal canal, the one that is never deficient, is that 
proved by anatomy to be the first formed ; this is the exten- 
sion of the vesicula umbilicalis, which may be found, either 
outside the abdomen, along the cord, in form of a small tube, 
or else in the abdominal cavity, forming a duct of variable di- 
mensions, and terminating at each end in a cul-de-sac. Accord- 
ing as the primary duct has extended more or less considerably 
above, or below, there will be found in the abdomen more or 
less extensive portions of the small or great intestine. The 
stomach, being one of the parts of the alimentary canal last 
formed, is also one of those most frequently found wanting. 
Sometimes, however, according to Elben, it has been found 
present, while there was very little appearance of any other 
part of the canal. If this be true, it would be in favour of the 
opinion of Wolf, who maintains that the gastro-intestinal tube 
is formed in separate pieces, which afterwards unite ; while 
according to Oken, Mekel, and Geoffroy St. Hilaire, it is form- 
ed in a single piece, which exists in the rudimentary state in 
constantly the same original situation, and gradually lengthens 
by throwing out two shoots, if I may use the expression, the 
one, superior, terminating at the cardiac orifice of the stomach, 
and the other, inferior, ending at the anal extremity of the rec- 
tum. Of the various malformations of which I have given a 



BELOW THE DIAPHRAGM. 



95 



sketch, there are many which seem to confirm, some the one, 
and some the other opinion. 

The congenital alterations of nutrition of the alimentary ca- 
nal may produce in it faults of configuration, of dimension, and 
of situation ; and, lastly, imperforation of one or more of its 
natural orifices. 



A. Faults of Configuration. 



The stomach is sometimes remarkable for the singularly 
lengthened or rounded form it assumes. In many persons it 
has a contraction in the middle, which seems to divide it into 
two parts. This generally proceeds from an alteration of 
texture or a contraction of the muscular coat, but is sometimes 
congenital ; and then seems to indicate in man the first degree 
of tendency to division of the stomach, a conformation which 
becomes more and more marked in beasts. However, if in 
man the stomach is naturally but a single cavity without trace 
of contraction or partition, this division does not the less begin 
to show itself in him by other characters. Thus, the structure 
of the mucous membrane of that vicus is certainly very far 
from being the same in its splenic and pyloric portions ; their 
physiological action appears to be equally distinct, and they 
have also a tendency to differ in the relative frequency, and 
even the nature, of their alterations of texture. In some ani- 
mals, the difference of organization of these two portions of the 
stomach is perceptible to the naked eye ; thus, in the horse, 
the whole internal surface of the splenic portion is lined with a 
thick epidermis. 

In some rare cases, instead of a simple median contraction, 
there is observed in the stomach a still greater tendency to di- 
vision ; it is divided into compartments by one or more incom- 
plete partitions, which thus give it a kind of resemblance to 
the compound stomach of the ruminantia. I once saw a case 
in which from the internal surface of the stomach there arose 
perpendicularly a number of laminee, several lines in height, 



96 DISEASES OF THE ALIMENTARY CANAL 

parallel to each other, and occupying chiefly the two faces of 
the body of the viscus; thus reminding me in some degree of 
the arrangement of that portion of the stomach of the rumi- 
nantia known by the name of maniplies. 

At other times, the human stomach, far from becoming more 
complicated, shows a remarkable tendency to become more 
simple, and loses some of its parts : thus the great extremity 
has sometimes been found wanting, and in such cases the 
oesophagus enters the left extremity, as in carnivorous animals. 

Fleishman describes a case in which the caecum presented 
a remarkable configuration, being completely bifurcated. 



B. Faults of Dimension. 

Cases are recorded by authors, in which the alimentary 
canal was singularly shortened, the convolutions of the small 
intestine being less numerous, or altogether wanting, and the 
length of the canal from the cardiac orifice to the anus scarcely 
equalling, or even falling short of, that of the individual. 
Amongst others, one is mentioned in which the gastrointes- 
tinal canal was reduced to the smallest dimensions possible, 
forming a straight tube which, commencing at the entrance of 
the oesophagus into the stomach, terminated, as usual, with 
the rectum, which occupied its ordinary situation. Thus, then, 
there have been found in man the three great varieties of ex- 
tent presented, in the series of animals, by the alimentary 
canal, which is sometimes longer, sometimes only as long, and, 
lastly, sometimes shorter than the body of the animal itself. 

The stomach is sometimes so little developed that its di- 
mensions do not surpass those of the small intestine, thus re- 
sembling the stomach of certain animals, which differs only in 
situation from the portion of intestine continuous with it. 

The caecum may be completely deficient ; in which case the 
ileum opens directly into the colon ; or, at least, if the caecum 
does exist, it does not form a cul-de-sac. According to 
M. Geoffroy St. Hilaire, this absence of the cascum may be 
explained by the primary mode in which the great portions of 



BELOW THE DIAPHRAGM. 



97 



the intestinal tube, the small and the great intestine, run into 
each other. The appendix vermiformis is sometimes shorter 
than usual ; at other times there is no trace of it to be found. 

The increase of dimension of the intestines constitute faults 
of conformation more numerous and various than those pro- 
ceeding from their diminution. 

Infants have sometimes come into the world with a stom- 
ach of such considerable size as to fill the greatest part of the 
abdominal cavity. In others the duodenum has been found 
almost as large as the stomach ; and, in a child that died a 
week after its birth, it was double. Immediately below the 
pylorus, which was completely obliterated, it divided into two 
canals, which re-united at about a third of an inch above the 
jejunum; the ductus choledochus opened into the largest of 
them : there was no other malformation.* Sometimes, also, 
the caecum has been found either of itself much larger than 
usual, or provided with a remarkably large appendiculum, or, 
lastly, really double, presenting two large culs-de-sac, one of 
which communicated with the colon. This latter is not un- 
frequently remarkable for its excessive length, and then neces- 
sarily presents several flexuosities in consequence of its in- 
creased dimensions. Brugnoni mentions a case in which two 
colons sprang from a single caecum and re-united at the rec- 
tum. In Meckel's platesf is a representation of a colon sim- 
ple at its origin, and near the caecum, then separated into two 
cavities by a central partition, and, at last branching out into 
two dilated portions of unequal size, that float freely in the ab- 
domen, and terminate in a cul-de-sac. It may happen that 
the same alimentary canal shall be found at once increased in 
size in one part, and diminished in another. Thus, Cabrol 
mentions a case of a person who had a stomach so large that it 
filled a great part of the abdominal cavity, while the great and 
small intestines together scarcely exceeded the length of three 



* Calder, Memoires de M^decine d'Edimbourg, 5 vol. 12mo. 
t Fascicula Anat. Pathol. 

Vol. II. 14 



98 DISEASES OF THE ALIMENTARY CANAL 

feet. In a monstrous foetus described by M. Geoffroy St. 
Hilaire under the name of podencephalus, he found that the 
small intestine was one-fifth shorter than the natural size, whilst 
the great, the colon especially, had acquired, with respect both 
to length and breadth, the enormous degree of developement 
it naturally has in herbivorous animals. 

The extent of the alimentary canal is sometimes increased, 
partially, by means of one or more appendices, that are attach- 
ed to it like the fingers of a glove, and form as it were small 
culs-de-sac placed along the course of the intestine, and com- 
municating with its interior. These appendices are known by 
the name of diverticula. They are most frequently situated 
on the jejunum and ileum, but have been seen on the duod- 
enum, and Morgagni found them even as far as the rectum. 
Of their two extremities, the one is continuous with the intes- 
tine ; the other, which is more or less remote from it, most 
commonly terminates in a cul-de-sac, and sometimes floats 
loosely in the abdominal cavity, while sometimes it adheres, 
either to the parietes of the abdomen, to the mesentery, or to 
another coil of intestine. This extremity has been found more 
or less open ; thus, Meckel saw one of these diverticula insert- 
ed into the navel, and there presenting a gaping aperture 
through which a probe could be introduced into the cavity of 
the intestine itself; the diverticulum, thus forming a kind of 
umbilico-intestinal canal, was accompanied by the omphalo- 
mesenteric vessels, which still remained. As to their form, 
many of these diverticula are found terminating in a point, 
others have a rounded extremity, and some present a series of 
dilatations and contractions, or more or less numerous em- 
bossments. They may be only some lines, or several inches 
long ; and the size of their cavity may surpass, equal, or fall 
short of, that of the portion of intestine with which they are 
continuous. They spring from the intestine at various angles, 
being sometimes perpendicular to it, and sometimes oblique ; 
some of them, even, are almost parallel to its axis, and as it 
were lie on its surface. Their number is various : in general 
there is but one ; sometimes there are more ; and as many as 
six have been found in the same subject, proceeding at short 



BELOW THE DIAPHRAGM. 99 

intervals from the same portion of intestine. The structure 
of their parietes mostly resembles that of the parietes of the 
intestines, and is sometimes even more fully developed, the 
different coats presenting a remarkable degree of hypertrophy. 
At other times, on the contrary, some of these coats are either 
but imperfectly developed, or altogether deficient. Thus, the 
muscular coat may be reduced to a few scattered fibres, that 
are scarcely perceptible ; or the parietes may consist solely of 
the mucous membrane, in which case it seems that the diver- 
ticulum is formed merely by a hernia of that membrane. 

According to Meckel, intestinal diverticula are merely traces 
of the original intestine formed by the vesicula umbilicalis. In 
support of this opinion he urges that the spot where a diverticu- 
lum is most frequently found, is precisely the one where, as he 
says, the vesicula umbilicalis begins to lengthen out into an in- 
testine, namely, the lower third of the ileum. But, in the first 
place, it is not quite certain that the first rudiments of the ali- 
mentary canal actually are formed in this spot ; and in the 
next, diverticula have been found in other parts, the duodenum 
and rectum. Besides, there is but one vesicula umbilicalis, 
whereas several diverticula have more than once been found 
in the same individual. Meckel endeavours to get rid of the 
difficulty by distinguishing the diverticula into true and false, 
and considers the first only, from their situation, confirmation, 
and texture, as traces of the umbilical vesicle after its trans- 
formation into the intestine. 



C. Faults of Situation. 



These must be divided into two classes : the first compris- 
ing those cases in which either the whole or a part of the ali- 
mentary canal is situated outside the abdominal cavity ; the 
second those in which it is contained as usual within the pa- 
rietes of that cavity, but its different parts no longer occupy 
their natural situation. The most remarkable case of this kind 



100 DISEASES OF THE ALIMENTARY CANAL 

is that in which there is a general transposition of the various 
parts of the intestine, so that what should be at the right side is 
placed on the left, and vice versa. Thus, the great extremity 
of the stomach occupies the right hypochondrium ; its pyloric 
orifice is situated below the false ribs of the left side ; the three 
curves of the duodenum occupy on the left the same situation 
they naturally do on the right, and their concavity looks to- 
wards the right side. The caecum occupies the left iliac region ; 
the ascending colon is situated at the left side, and the descend- 
ing colon terminates in the sigmoid flexure, which lies in the 
right iliac fossa. In this case, there is also a transposition, as 
well of the other abdominal viscera, such as the spleen and 
liver, as of the thoracic, the vertex of the heart beating at the 
right side, and the lung on the left having three lobes. 

Partial faults of situation principally affect the transverse 
colon, which sometimes passes in front of the stomach, some- 
times is covered by it, and some has its convex side turned 
downwards, being so disposed as to form an arch whose 
convexity is below, and much nearer the pubis than the 
stomach. 

To the other class belong congenital hernias. In order to 
conceive how they are formed, we must recollect that the ab- 
dominal parietes are not formed until pretty long after the ap- 
pearance of the viscera which they are to protect, so that till 
about the end of the second month, the foetus seems to have its 
different organs outside the abdominal cavity, while in reality 
the latter does not yet exist. If the abdominal parietes hap- 
pen to be arrested in their developement, the intestines may 
present themselves at birth in the same situation in which they 
are found at the earliest period of foetal life, that is to say, ap- 
parently outside the abdominal cavity. The parietes may, 
moreover, be faultily developed, being formed behind the vis- 
cera, which will then be really situated outside the abdomen ; 
but then it cannot be said, in such cases, that they have gone 
out of it, since they had never been contained in it. 

The abdominal parietes may be wholly wanting; and then 
there is not only no vestige of the different tissues that form 



BELOW THE DIAPHRAGM. 



101 



them anteriorly and laterally, but the diaphragm itself is also 
deficient: this generally co-exists with an imperfect develope- 
ment of the parietes of other cavities, such as absence of the 
sternum, spina bifida, greater or less fissure of the top of the 
cranium, hare lip, &c. In other cases, but one of the parietes 
is wanting: this is sometimes the superior, and then the tho- 
racic and abdominal cavities are confounded into one ; it is ob- 
served that in such cases the lungs are generally but very lit- 
tle developed. At other times the diaphragm is well formed, 
and the front of the abdomen is wanting either wholly, or on 
one side. Moreover, either may be very imperfect with res- 
pect to the number and the quality of its anatomical compo- 
nent parts. Thus in place of the muscular partition usually 
interposed between the cavities of the thorax and abdomen, 
there may be a simple cellulo-fibrous web, such as exists natu- 
rally in certain animals. The front of the abdomen may also 
be deficient in its muscular part, and consist only of the cellu- 
lar, fibrous, serous, and cutaneous tissues. The last mentioned 
tissue often stops short on the lateral parts of the abdomen, 
leaving in front nothing but a layer of cellular tissue more or 
less condensed. In this case, the different tissues which, taken 
together, form the regular parietes of the abdomen, exist singly, 
as the tissues that concur in the formation of the parietes of 
the cranium or spinal canal do in anencephalia and spina bifida. 
In other cases the deficiency exists only in the median line, 
and in place of the linea alba is found a longitudinal cleft 
through which the viscera appear. If it be true that the ab- 
dominal parietes are formed of two lateral parts which are at 
first separate, and afterwards meet and unite in the median 
line, it may be readily understood that the existence of a cleft 
in the place of the linea alba indicates an unfinished process of 
organization. 

This cleft itself may diminish, and consist only of an aperture 
existing at the umbilicus, or near it; and it sometimes happens 
that the most of the mass of the abdominal viscera is found in 
front of this aperture. Lastly, in other cases, there is nothing 
uncommon in the conformation of the abdominal parietes ex- 



102 DISEASES OF THE ALIMENTARY CANAL 

cept that the natural orifices, especially the inguinal ring, are 
larger than usual.* 



D. Imperforation of the Natural Appertures, and preternat- 
ural Communication between the Intestines. 



The malformations accompanying this imperforation may be 
ranged in three classes. 

Class I. This comprises those cases in which the cavity of 
the alimentary canal is interrupted in but a single point of its 
extent, its parietes still forming one continued whole. The ob- 
struction is often formed by a membrane placed perpendicularly 
to the parietes of the intestine, and intercepting all communi- 
cation between the portion of the canal above it and that below. 
At other times, instead of a simple membrane, of which the 
perforation would re-establish the continuity of the intestinal 
canal, the intestine forms a solid cord for a certain extent, in 
consequence of the intimate agglutination of its parietes. It is 
in the rectum these different malformations have most fre- 
quently been discovered. 

Class II. This comprises the cases in which there is an in- 
terruption not only of the canal, but even of its parietes. Thus, 
the oesophagus has been found completely separated from the 
stomach, and that from the duodenum, as also the colon from 
the rectum. The small intestine has likewise been found ter- 
minating in a cul-de-sac at a certain height, and the subsequent 
portion recommencing a little lower down, its extremity being 
also a cul-de-sac, and then going on as usual to the great in- 
testine. 

Class HI. In this, as well as in the second class, the intestine 
terminates in a cul-de-sac in some point of its extent, but there 



* The plan of this work, and the limits I have marked out to myself, do not 
allow me to treat of accidental hernia occurring after birth. I could but copy 
the excellent descriptions of it that have been already given in surgical works, 
and to these I must refer the reader. 



BELOW THE DIAPHRAGM. 103 

is no trace of it to be found lower down, and its place is occu- 
pied only by a cellular tissue. Thus, the great intestine may 
consist only of the cascum, or in a rudiment of the colon; or 
the latter may be complete, and terminate at the sigmoid flex- 
ure by a blind extremity. Lastly, there may be a beginning 
of the rectum, which remains unfinished, if I may use the ex- 
pression, and terminates in a belly without any apperture, at a 
distance more or less remote from the spot where the anus is 
usually situated. 

Whether the anus exits or not, the alimentary canal some- 
times presents preternatural communications as well with the 
exterior, the opening being then at the navel, immediately above 
the pubis, or under the penis, as with different hollow organs, 
such as the bladder or vagina. In this last case, there is a ten- 
dency to the confusion of the external orifices of the digestive, 
urinary, and genital organs, and the formation of a common 
cavity more or less closely resembling the cloaca in birds. 



ARTICLE III. 



LESIONS OF SECRETION. 



The lesions of secretion, which frequently occur in the ali- 
mentary canal, and form in it various diseases, should be studi- 
ed, 1. on the free surface of the mucous membrane ; and, 2. 
in the substance of the different other tissues that contribute to 
the formation of the gastro-intestinal parietes. 

§ I. Morbid Secretions on the Mucous Membrane. 

These are of two kinds ; the one being the natural secretions 
merely increased in quantity ; the other new secretions. 



104 DISEASES OF THE ALIMENTARY CANAL 



A. Natural Secretions increased in Quantity. 



These are the mucus, the perspirable vapour, and the gases. 

On opening bodies, one is sometimes struck with the prodig- 
ious quantity of mucus on the internal surface of the stomach 
or intestines. This often forms a thick layer extending over a 
great portion of the intestine, which, at first sight, might be taken 
for the mucous membrane itself, and that, too, white and healthy. 

Beneath this layer of mucus, the internal surface of the canal 
may appear in two opposite states. In the first place, the mu- 
cous membrane may be of a bright red, and this is even the 
most usual case ; but it may also be pale and without the least 
trace of injection, the increase of a secretion not necessarily in- 
ferring the formation of a sanguineous congestion in the secre- 
ting organ. The mucous membrane that lines the superior sur- 
face of the tongue presents, in this respect, the greatest analogy 
with what is found on opening the body in that part of the ali- 
mentary canal that is concealed from view during life. Thus, 
at the same time that it is loaded with an unusual quantity of 
mucus, it is itself sometimes of a bright red, sometimes of its 
natural colour, and, lastly, sometimes evidently paler than nat- 
ural. 

In place of mucus, there is occasionally found in the intesti- 
nal tube an enormous quantity of a fluid resembling water. 
This seems to be merely the vapour usually exhaled by the mu- 
cous membrane, which, being increased in quantity, appears in 
the fluid form. In such cases it may be said that the mem- 
brane really sweats. This remarkable increase of exhalation 
may take place by an acute process ; as occurs in certain ca- 
ses of cholera morbus, in which the abundant evacuations that 
are observed do not always contain bile, and sometimes consist 
solely of a fluid resembling serum. In such cases, on opening 
the body, the mucous membrane is found pretty strongly con- 
gested, and that is all ; just as a redness of the skin accompa- 
nies a perspiration. But, the cutaneous surface is not red and 



BELOW THE DIAPHRAGM. 105 

hot every time it gives out an abundant serous exhalation ; it 
may be covered with sweat, although cold and pale. The same 
is the case with the intestinal mucous membrane, which, with- 
out becoming red, may likewise exhale an abundance of serum. 
On -opening the bodies of persons who had had a serous diar- 
rhoea unattended with pain, at the end of various chronic dis- 
eases, I have frequently been struck with the state of the small 
intestines ; their parietes, which were attenuated and remark- 
ably pale, being distended with a serous fluid, sometimes col- 
ourless, and sometimes of a slight yellow tinge. Old writers 
describe, under the name of dropsy of the stomach, a lesion 
which seems to me to have some relation to that which I have 
just mentioned as existing in the small intestine. The stom- 
ach is in like manner filled with a great quantity of serous fluid, 
its size is considerably increased, it occupies the greatest part 
of the abdominal cavity, and at the same time its parietes are 
exceedingly attenuated. I saw myself a case of this kind, in 
which the great curvature of the stomach almost reached the 
pubis, and the fluid that filled its enormous cavity could be seen 
through the transparent tissue of its delicate parietes. In this 
case, the stomach presented no appreciable lesion ; very unlike 
another enlarged stomach already mentioned, in which the py- 
lorus was also diseased. 

The researches of modern physiologists have proved, that, 
in the healthy state, the alimentary canal always contains a 
certain quantity of gases, whose nature has been ascertained 
by chemical analysis. In the morbid state, these gases some- 
times increase in quantity to such a degree as to distend the in- 
testine and produce several bad effects. 

Of the various portions of the canal, the colon is the one in 
which the morbid accumulation of gases most frequently oc- 
curs. It may then be distinguished through the abdominal pa- 
rietes, and thrusts up the diaphragm, sometimes producing a 
dyspnoea, which may be the more readily confounded with 
dyspnoea from hepatization of the lungs, as the liver, being push- 
ed up with the diaphragm, may give a very dull sound as far up 
as the right breast. 

Vol. II. 15 



106 DISEASES OP THE ALIMENTARY CANAL 

An increase of the gaseous secretion of the alimentary canal 
often accompanies a state of acute irritation of the mucous 
membrane; thus, it is frequently observed in persons in whom 
Peyer's glands are diseased, whether the affection be simply 
hyperaemia and enlargement, or, still more, ulceration. How- 
ever the single circumstance of the existence of ulcers in the 
intestinal tube does not necessarily produce an increase in the 
gaseous secretion; in fact, the ulcerated intestines of phthisical 
persons are seldom found distended with gases. 

On the other hand, I have more than once found the intes- 
tines greatly inflated without presenting any lesion after death, 
in persons who had died of an acute affection of the brain. 
Moreover, it does not appear to me certain, that, in typhoid 
fevers, meteorismus necessarily announces the existence of ul- 
cers in the intestines. Perhaps we should be nearer the truth 
in allowing that the production of gas in the intestines is often, 
though not constantly, connected with a state of ulceration ; 
and that, like such ulceration, it is an effect of the morbid cause 
which produces that assemblage of symptoms that have been 
provisionally designated by the generic term of typhoid fever. 
We arc to observe, again, that the ulcers are chiefly situated in 
the small intestine, while it is the great intestine that is most 
frequently affected with tympanitis. 

But, if any one should doubt that an increase of the gaseous 
secretion of the alimentary canal could take place without any 
lesion of circulation or nutrition in its parietes, I shall bring for- 
ward the remarkable fact of tympanitis being so frequently 
observed in hysterical women. What do we observe in such 
cases ? An indubitable modification of the innervation, and a 
tympanitis accompanying this modification sufficiently often to 
be fairly considered as one of its results. We should then con- 
sider what may occur with respect to the secretion of gas, in 
typhoid fevers, where innervation certainly plays a very great 
part, whether it be primary or secondary. The mere chemic- 
al reaction of the alimentary substances introduced into the 
digestive passages is often a cause of tympanitis. Veterinary 
surgeons are well aware, that by feeding sheep in a certain 
manner, there is such a developement of gases produced in 



BELOW THE DIAPHRAGM. 107 

their paunch, that they die of suffocation if the gases be not 
suffered to escape by plunging a trocar into it through the pari- 
etes of the abdomen. 



B. New Secretions. 



a. Blood. This fluid is occasionally, found in the stomach or 
intestines, both in the fluid, and in the coagulated state ; it some- 
times occurs only in small quantities, and then in a few points, 
and sometimes in such abundance as to distend the parietes of 
the containing cavity. 

The causes of this effusion of blood on the internal surface 
of the alimentary canal are the following: 

1. A mechanical obstacle to the circulation through the vena 
portae: this has already been considered. 

2. Irritation of the gastro-intestinal mucous membrane. Thus 
the introduction of certain corrosive poisons into the stomach 
produces haematemesis: and certain drastic purges cause bloody 
stools. As for the rest, by varying to infinity the degrees or 
modes of irritation, we can no more produce at will a haemor- 
rhage from the stomach or intestines, than we can, a softening 
or ulceration of the same parts. 

3. A sanguineous congestion, which is neither mechanical, 
as in the first case, nor produced by an evident process of irri- 
tation, as in the second. The blood accumulates in some part 
of the texture of the mucous membrane, and escapes from its 
vessels; which is all that we can discover. 

4. Certain states of the blood itself, in which it is so changed 
as to have a universal tendency to escape from its vessels. 
This is what occurs in certain cases of poisoning by absorption, 
and in typhus fevers. In these, the frequent haemorrhages 
from the digestive mucous membrane no longer result from a 
primary alteration of the membrane itself, but are one of the 
elements of a morbid state which exists wherever the blood 
has access; the black vomit in the yellow fever is one of the 
most striking instances of such haemorrhages. 



103 



DISEASES OF THE ALIMENTARY CANAL 



5. Lastly, we must not forget that the blood that is found in 
the stomach or intestines may have been swallowed. This 
happens in certain cases of abundant haemoptysis, and, still 
more, when an aneurism of the aorta opens into the oesophagus. 
In the latter case, the stomach is found distended by an enor- 
mous coagulum. 

Whatever be the cause of the presence of the blood in the 
alimentary canal, its internal surface in such cases is sometimes 
found more or lesss strongly injected, and sometimes, on the 
contrary, very pale. I found it scarcely traversed by a few 
middling sized vessels, and the capillaries not injected, in a per- 
son who sunk in less than an hour under a very abundant haem- 
orrhage, which came from the anus during the course of a 
slight fever. The mucous membrane was covered with a 
quantity of blood from the commencement of the ileum to the 
rectum, so that the source of the haemorrhage could not be mis- 
taken. In neither case is there found in the alimentary canal 
any special lesion by which it could be discovered after death, 
from an examination of the canal, that a gastric or intestinal 
haemorrhage had taken place during life. Nor was the lesion 
more peculiar in the cases of two person who died of haemat- 
emesis, and were opened by professor Lallemand of Montpel- 
lier.* In each, the mucous membrane of the stomach, for an 
extent of three or four inches, was puffy, and of a crimson col- 
our, permitting the blood to exude from it on pressure, and so 
easily torn that at the least touch it came off in shreds. Intes- 
tinal haemorrhage is not very uncommon in new-born infants; 
M. Billard saw fifteen cases of it in the space of a year, of 
which eight occured between the first and sixth day, four be- 
tween the sixth and eighth, and three between the tenth and 
eighteenth. In all these cases he could not discover any thing 
peculiar in the intestinal parietes but that they were more or 
less strongly injected. Some of the children were plethoric; 
others, on the contrary, pale and weakly. In all of them the 
lungs, heart, liver, spleen, large abdominal vessels, nervous cen- 



* Premtire letlre eur VEncephale, pag. 93. 



BELOW THE DIAPHRAGM. 109 

tres, and their investing membranes, were found gorged with 
blood. Thus, then, haemorrhage may take place from the sur- 
face of the intestines, as it does from every other mucous mem- 
brane, without there being necessarily any serious lesion of the 
tissue from which the blood escapes. This fact explains to us 
how haemorrhage from the alimentary canal can have occurred 
frequently in the same individual, without being followed by 
any serious consequences. One of the most remarkable cases 
of this kind is that described in the 14th volume of Corvisart's 
Journal, relative to a woman who for fifteen years had had fre- 
quent attacks of haematemesis, without her health being in any 
way injured by it. At the end of the fifteen years the vomit- 
ings of blood ceased, and were succeeded by a sanguineous 
exudation from different parts of the skin : the catamenia had 
always been regular. The haematemesis first appeared subse- 
quently to her receiving a blow on the epigastrium from the 
horn of a cow. In September, 1828, there was at La Charite 
a woman who for several years had had haemorrhages from 
the lungs, stomach, and uterus, at different times; in the inter- 
vals between the attacks, none of these organs appeared to be 
affected with any lesion. But, on the other hand, in the ali- 
mentary canal, as in every other part of the body, it happens 
not unfrequently that constant lesions give rise at intervals to 
more or less abundant haemorrhages ; they cannot, however, of 
themselves, account for the haemorrhage, being only its occa- 
sional cause. Thus, we learn from observation, that in many 
cases in which the stomach is affected with a so called scirrhous 
thickening of its submucous cellular tissue, the mucous mem- 
brane gives out at intervals a sanguineous exudation; and it is 
a serious mistake to imagine that the haematemesis that fre- 
quently accompanies the affection known by the name of can- 
cer of the stomach, occurs only in those cases where the mu- 
cous membrane is already ulcerated. I have in more than one 
instance found it appearing perfectly sound, where it lay over 
a tumour consisting of a mass of indurated cellular tissue, in 
persons who had had a copious haematemesis shortly before 
their death. I find in my note-book the case of a person affect- 
ed with scirrhus of the descending colon, who sunk under haem- 



110 DISEASES OF THE ALIMENTARY CANAI/ 

orrhage from the rectum. On opening the body, there was 
not the least trace of ulceration to be found in the intestine ; the 
mucous membrane was sound and almost colourless through- 
out; and where the transverse joins the descending colon, it 
was raised up by a mass of indurated cellular tissue, which in 
a great measure obstructed the intestinal cavity. In all these 
cases, then, we find gastro-intestinal haemorrhage preceded or 
accompanied by lesions varying in nature and intensity. There 
is another, more uncommon, in which there is found on the in- 
ternal surface of the stomach or intestines a lesion wholly phys- 
ical, that has been of itself the cause of the haemorrhage; this 
is the solution of continuity of- a large vessel, which is then 
found gaping in the interior of the canal. Such an occurrence 
is, however, much rarer than one would be inclined to think; 
and there are at most but five or six well authenticated in- 
stances of it. The following is one, which deserves to be quot- 
ed on account of its singularity: it is recorded by M. Prost.* 

A man expired just as he was taken in at La Charite. On 
opening the body the stomach was found full of coagula of 
blood ; in its great extremity was an ulcer, which, from its in- 
durated margin, was evidently of long standing. At the bot- 
tom of this ulcer appeared the gaping orifice of a large blood- 
vessel, which readily admitted a probe. 

I have mentioned elsewheref a remarkable case of a person 
in whom a large vessel was found open at the bottom of an ul- 
cer in the stomach, although there had not been any haemor- 
rhage during life. 

It has been said that the most common cause of gastro-in- 
testinal haemorrhage is the developement of varices on the in- 
ternal surface of the canal. Now, this cause must be, at least, 
uncommon ; since, for my own part, often as I have opened 
bodies, I have never found, either in the stomach or intestines, 
any varices properly so called. As I have already said, I have 
only met with, occasionally, some dilated veins, which had 



* Medecine eclairee pur POuverture des Corps. 
t Clihique Medicate. 



BELOW THE DIAPHRAGM. Ill 

nothing in their appearance in common with those varicose 
veins on the skin, or around the anus, which from time to time 
pour out a certain quantity of blood. 

b. Melanosis. Instead of exuding blood, the gastro-intestinal 
mucous membrane sometimes exudes a black matter, in which 
most of the elements of that fluid are discovered, but which 
differs from it in appearance, and in the circumstances under 
which it shows itself. This is the same substance which, in 
the first volume of this work, has been described in a general 
manner by the name of melanosis. 

The alimentary canal of certain animals is naturally colour- 
ed by this matter ; this is observed particularly in many of the 
fish tribe. In that of man, and other mammalia, it is to be 
considered as a preternatural secretion, but yet as one which 
in many cases no more gives rise to any morbid phenomena, 
than are produced in the lungs by the black matter which so 
often stains both the parietes of the air vessels and the inter- 
lobular cellular tissue. 

In man, the black matter makes its appearance in the intes- 
tinal canal in two states : 1, as a fluid, lying free on the internal 
surface of the intestine ; and, 2. combined with the tissue of the 
mucous membrane. 

I once showed at the Academie Royale de Medicine a great 
intestine whose internal surface was tinged with a black colour 
as deep as that of Indian ink. This was owing to the presence 
of a fluid layer deposited on the mucous membrane, which 
gave a black stain to linen when rubbed to it, as if it had been 
the choroid. The layer was removed by washing, and the 
membrane beneath it remained black. 

I found the same black substance in the stomach of a woman 
fifty years old, that died at La Charite. It was half full of a 
fluid as black as ink, which, when rubbed on white paper, gave 
it a tint resembling what would have been given by the choroid. 
The interna] surface of the stomach, on being washed and 
wiped, was found sprinkled with a great number of spots of a 
deep black colour, and of various sizes, the largest being about 
the size of two-franc pieces, and the smallest resembling mere- 
ly black dots. Around some of these spots, the mucous mem- 



112 DISEASES OP THE ALIMENTARY CANAL 

brane was of a livid red, which was pretty strongly marked for 
the space of a few lines all round the spot, and became less 
perceptible as the distance increased. Around the others, be- 
tween them, and every where else, the internal surface of the 
stomach was pale, and the mucous membrane presented no ap- 
preciable alteration with respect to its thickness and consit- 
ence. The black tint was situated in the mucous membrane 
only, but it occupied its whole thickness, and was equally dis- 
tinct on both surfaces. In some parts the cellular tissue subja- 
cent to the black spots was reddish. Where the mucous mem- 
brane was stained, it was a little thicker and firmer than else- 
where. 

In another subject, instead of the black spots just described, 
I found long black lines, five or six in number, extending from 
the pyloric to the cardiac orifice of the stomach : the mucous 
membrane, which was entire, but somewhat attenuated, was 
sensibly depressed in their tract ; so that they might be com- 
pared to traces left on the skin by nitrate of silver. These 
lines stained linen black, and the colouring matter in this case 
also seemed merely deposited on the mucous membrane. 

In this, and the preceding case, there had not been during 
life any well marked sign of a gastric affection. Besides being 
interesting in a theoretical point of view, they also seem of im- 
portance with respect to the application that may be made of 
them to forensic medecine. In fact, if there was a suspicion 
of poison, and similar black spots were observed in the stom- 
ach, might not a careless or ignorant examiner be led to con- 
found them with the gangrenous patches produced on the pa- 
rietes of the stomach by sulphuric acid ? 

Instead of being deposited on the internal surface of the gas- 
trointestinal parietes, as in the preceding cases, the black mat- 
ter may be combined with the texture of the tissues which 
compose these parietes ; the mucous membrane then still pre- 
sents a fine black colour, but it can no longer be removed by 
washing, and the matter that composes it does not stain linen. 
This black matter exists specially, 1. at the bottom of the nu- 
merous lacunae that are often very apparent in the duodenum ; 
2. at the vertex of the villi of the small intestine ; 3. at the cir- 



BELOW THE DIAPHRAGM. 



113 



cumference of the orifices of Peyer's glands. In the first case, 
the duodenum seems as it were overspread with a more or less 
considerable number of small black spots. In the second, the 
internal surface of the small intestine is sometimes dotted with 
black, and sometimes, when a greater number of villi are col- 
oured, or when the colouring extends farther than their ver- 
tices, presents a uniform black tint. Lastly, in the third case, 
there are found, in the situation of Peyer's glands, a number 
of small black points, which form by their assemblage an oval 
or roundish figure ; they have been pretty accurately compar- 
ed to the hairs of a beard recently shaved. 

c. Pus. The mucus usually secreted in variable quantities 
on the internal surface of the alimentary canal, may be replaced 
by various other secretions, which are found either scattered 
through the gastro-intestinal cavity, or contained in the follicles. 

The first of these I shall notice is pus ; but it is much less 
frequently found on the free surface of the digestive mucous 
membrane than one would imagine. I once found the whole 
of the colon lined with a deep layer of thick pus, exactly re- 
sembling that of a phlegmonous abscess. It is more frequently- 
met with in follices, which then form on the surface of the in- 
testine small tumours, from which the pus escapes on a slight 
incision being made in them. 

d. Tuberculous matter. Instead of pus, the follicles more fre- 
quently contain a concrete, whitish, more or less friable sub- 
stance, resembling the so called tuberculous matter. The 
internal surface of the whole intestine is occasionally found 
studded with a great number of small white bodies, which are 
nothing but follicles filled with this kind of substance. In man, 
those follicles that thus retain their own morbid secretion rarely 
attain any considerable size, being scarcely ever known to ex- 
ceed the bulk of an ordinary pea ; but, in the horse, under the 
same circumstances, they may become much larger. Thus it 
is by no means unusal to find, on the interior of the intestinal 
tube, in horses, tumours of about the bulk of a small orange, 
which are hollow, and generally contain a substance more nearly 
resembling the sebaceous matter furnished by the cutaneous 
follicles than any thing else. On examining these tumours at- 

Vol. II. 16 



114 DISEASES OF THE ALIMENTARY CANAL 

tentively, we find on the surface of many of them an orifice that 
always looks in the same direction, and through which the con- 
tained matter may be squeezed out by pressure. It seems to 
me very evident that these tumours are nothing but follicles 
altered both in their nutrition and in their secretion; the affec- 
tion being, if I may use the expression, a genuine acne of the 
mucous membrane. 

e. False membranes. In the two preceding cases, we have 
seen that the morbid secretion remained within the parts that 
produced it : but, the contrary may occur ; and, instead of re- 
maining solely in the follicles, a concrete matter, likewise se- 
creted by them, may come out, and spread in a more or less 
thick layer over the gastro-intestinal mucous membrane. Hence 
occurs the formation of false membranes on the internal surface 
of the alimentary canal; but that may also take place without 
the assistance of these follicles, merely by means of an altera- 
tion of the perspiratory action that resides in every living 
particle. 

The mucous membrane of the alimentary canal is much 
more subject to the formation of false membranes in its supra- 
diaphragmatic, than in its infra-diaphragmatic portion. In child- 
ren, for instance, we often find the mouth, pharynx, and oesoph- 
agus, lined with a vast membraniform exudation, which ends 
abruptly before it reaches the stomach. Exceptions to this 
rule are very rare indeed ; thus, of two hundred and fourteen 
cases of aphthae that were observed in 1826 at the Hopital des 
Enfans-Trouves, M. Billard found false membranes in the 
stomach, in but three; and in the intestine, properly so called, in 
but two. M. Lelut, to whom we are indebted for an excellent 
work on aphtha?, has not seen them more frequently in the 
stomach, and has never seen them in the intestine. 

In persons more advanced in age, false membranes on the 
infra-diaphragmatic portion are equally uncommon. I saw a 
very remarkable instance of it in a young girl of twelve years 
of age, in whom all the air passages were lined with false mem- 
branes, which were found also in the pharynx, oesophagus, and 
stomach, where they existed in form of large bands extending 
from the cardiac to the pyloric orifice, beyond which point they 



BELOW THE DIAPHRAGM. 115 

did not reach ; the mucous membrane was much redder be- 
neath them than in their intervals. 

After puberty, the formation of false membranes on the inter- 
nal surface of the stomach and intestines is still very uncommon. 
I have never seen any either in the stomach or small intestine. 
I twice found the internal surface of the rectum, and once that 
of part of the colon, lined with a semi-concrete layer resemb- 
ling thick cream, in which no trace of organization could be 
discovered, and which could not be removed in a tubular form. 
However, cases have been mentioned of persons passing by 
stool considerable portions of membranes of sufficient consist- 
ence to make an inattentive observer imagine that the mucous 
membrane itself was detached from its subjacent tissues, and 
expelled by the anus. 

In the few well authenticated cases of false membranes in 
the stomach or intestines, they have been described as follows. 

The false membranes found by M. Billard in the stomachs of 
three children, of whom one was four, and the other two were 
six days old, appeared to him to consist of an aggregation of 
small white points situated over the villi of the mucous mem- 
brane, to which they adhered strongly, and which were very 
projecting, tumid, red, and bloody at their extremity. In the 
cases observed by M. Lelut, he found, like M. Billard, that the 
false membrane was arranged in points, which in some parts 
were conical, and covered a considerable space, and in others, 
were isolated. In two of the cases mentioned by M. Billard, 
there were found along the small curvature several follicles in 
a state of tumefaction, and surrounded with a red circle ; but 
it was not in that part of the stomach the false membranes 
were situated. It seems, then, that the villi take a much more 
active part in the production of these membranes than the fol- 
licles do ; this, however, applies only to the infra-diaphragmatic 
portion of the alimentary canal ; for, in the mouth and pharynx, 
as well as in the air passages, the mucous membrane has no 
villi ; and yet false membranes are formed there much more 
frequently than in the stomach. 

In the intestine, the same arrangement is found as in the 
stomach, the false membranes there formed appearing to M. Bil- 



11G DISEASES OF THE ALIMENTARY CANAL 

lard like a mass of whitish flocculi, which adhered so strongly 
to the villi, that they could not be detached by scraping them 
strongly with the scalpel. Some of them, however, were found 
in the fsecal matter. 

f. Calculous concretions. Anatomists have long been aware 
that calculous concretions may form, or abide, in various parts 
of the alimentary canal. Thus Bonetus, in his Sepulchretum 
anatotnicum, relates a case of a stone almost as large as an egg 
being found in the stomach of a woman. He mentions another 
case of a soldier who could not eat without experiencing se- 
vere pains in the epigastrium, and in whose stomach was found 
a calculus of the size of an egg, that weighed four ounces, and 
was studded with rough points of an ashy colour. Lastly, 
there is in the same work an account of a person whose stom- 
ach contained nine stones enveloped in thick mucus, which all 
together weighed three ounces three drachms. 

More modern observations have shown that concretions of 
various sorts and forms may take up their abode in the alimen- 
tary canal, where their presence may be productive of various 
bad effects. 

The name of intestinal concretions has been given to sub- 
stances as various in their origin as in their nature. With re- 
spect to their origin, they may be divided into three classes : 
the first consisting of those which are not formed in the alimen- 
tary canal itself, but in the liver, or elsewhere, whence they 
proceed into the intestine, take up their abode there, and be- 
come more or less modified ; the second, of those which are 
only partly formed in the canal, consisting of a nucleus, which 
is generally some foreign body, around which certain elemen- 
tary particles contained in the canal collect, and crystallize ; so 
that without the presence of the nucleus the calculus would not 
have been formed ; and, lastly, the third, of concretions wholly 
formed in the alimentary canal. 

We may perceive from this that the composition of intestinal 
concretions must be very variable. In the first place, the con- 
cretions of the first class are almost exclusively formed of the 
component parts of the bile ; and it is even by this they are 
distinguished. Accordingly they consist of cholesterine, and 



BELOW THE DIAPHRAGM. 117 

of the yellow colouring matter and the resin of the bile. We 
must also refer to the first class a calculus found by Dr. Mar- 
cet in the rectum of a child in whom the anus was imperforate, 
and a preternatural communication existed between the rectum 
and the bladder. This calculus, which was as large as a nut, 
consisted principally of a mixture of phosphate of lime, and of 
the ammoniaco-magnesian phosphate. 

The composition of the concretions of the second class must 
be as various as that of the substances that form their nucleus. 
Thus, in the intestines of many animals are frequently found 
masses of hair, enveloped in salts and mucous matter more or 
less concrete. This hair is swallowed by the animal when it 
licks itself. Concretions of this kind have even received a 
particular denomination, being known by the name of cega- 
gropili. 

Amongst the lower order, in Scotland, who live principally 
on oaten bread, intestinal concretions are often found with 
their centre consisting of vegetable fibres. Their external 
layer is solid, compact, soft to the touch, and composed of sa- 
line matter ; in other instances it has a velvety appearance, 
and consists of very fine fibres closely united. Balls of oats 
are sometimes found scattered among them. Marcet has de- 
scribed these concretions as formed of compact layers, consist- 
ing alternately of fibrous substances and of earthy phosphates. 
The analysis of one of them gave the following result : — 

Animal matter ' 25.20 



Resin 



3.90 



Ammoniaco-magnesian phosphate .... 5.16 

Phosphate of lime 43 34 

Vegetable fibres ....... 20 30 



99.90 



The vegetable fibres were cemented together by deposits of 
earthy matter, consisting of the phosphate of lime, and the am- 
moniaco-magnesian phosphate ; which same salts also formed 
a coat around the entire mass. 

MM. Laugier and Lassaigne found in the centre of a calculus 
taken out of the intestines of a horse, which consisted of earthy 



118 DISEASES OF THE ALIMENTARY CANAIi 

phosphates, a great quantity of small pieces of straw, around 
which the saline matter had been deposited. 

I once found in the duodenum a hard concretion, of the size 
of a small egg, whose exterior consisted of a whitish, earth- 
like matter, and in whose centre was a plum stone. 

Dr. Crockelt, of the United States, has given an account of 
a young person, who, while quite a child, swallowed a brass 
pin, which, when the person was eighteen years old, was 
passed by stool, in consequence of the administration of a dras- 
tic purgative during the course of a bilious fever. The head 
and half the stem were contained in a spheroidal calcareous 
concretion.* 

One of the most curious instances of intestinal concretions 
that have been analyzed, is that given us by M. Laugier.f 
The concretion in question was pretty large, and completely 
stopped up the orifice of the rectum ; it resembled felt. When 
treated with boiling water, it coloured it, giving out a seventh 
of its weight of animal matter, of which the smell resembled 
faeces ; it also gave out a small quantity of hydrochlorate of 
ammonia and lime. When calcined it left eight hundredths of 
its weight of residuum, which consisted of phosphate of lime, 
a little silex, and oxide of iron. 

In the midst of this concretion was a cavity, containing a 
nucleus that differed greatly in its nature from the surrounding 
matter ; it was of a flattened prismatic form, and was covered 
with a blackish brown crust, a millimetre (.03937 inches) in 
thickness, and with a smooth, glossy surface. When a longi- 
tudinal section of it was made, its interior presented a great 
number of cells, arranged like those of bones that have lost 
some part of their gelatine, though still preserving some elas- 
ticity. It was found on analysis that the nucleus was formed 
of two substances, the one external, consisting of dried blood, 
and the other internal, being nothing but a fragment of bone. 



* North American Medical Journal, 1827. 
f Mimoires de VAcademie Royale de Medecine, vol. i. 



BELOW THE DIAPHRAGM. 



119 



It is highly probable that the original nucleus of this concre- 
tion was the portion of bone, and that this caused an effusion 
of blood around itself, which in its turn acquired a coating of 
various substances contained in the intestine. 

Lastly, I must not omit to mention, that there have been 
sometimes found, in the intestines of persons who had taken a 
great deal of magnesia, concretions formed of that substance 
cemented together by thick mucus. 

Concretions of the third class are in general formed solely of 
hardened faecal matter, of the consistence of real calculi. 

I think we should also refer to the third class some hard con- 
cretions that were passed in great numbers with the alvine 
evacuations by a young girl in a consumption, and were found 
by M. Lassaigne to be composed as follows : — 



matter con- \ Elaine > ... 74 



A fatty acid ( Stearine in great quantity 

matter con- \ Elaine 

sisting of V A particular acid 

A substance analogous to fibrine 21 

Phosphate of lime 4 

Chloride of sodium 1 



100 



Whatever be the origin and nature of the concretions, they 
may, by reason of their form, bulk, and situation, sometimes act 
as irritating bodies, and give rise to symptoms that do not cease 
till after their expulsion, and sometimes act merely by opposing 
a mechanical obstacle to the free passage of the contents of the 
intestines. I shall now give a few examples of these two kinds 
of effects. 

Case I.* A man, sixty years of age, had for a long time ex- 
perienced, whenever he took any food, violent spasms in the 
stomach, accompanied by a sensation of burning heat in that 
organ, and the eructation of a fluid so acrid as to ulcerate the 



* Case observed by Dr. Helm, of Stolp, translated from the German, in vol, 
viii. of the Bulletin des Sciences Medicates. 



120 DISEASES OF THE A1.IMENTA.RY CANAL 

pharynx and corrode the enamel of the teeth ; in addition to 
this, he laboured under vomitings, which recurred several times 
a day, a continual feeling of weight and distress in the pra- 
cordia, dislike to food, habitual constipation, and almost total 

sleeplessness ; at last he fell into a gradual decay 

One day, while vomiting, he threw up a calculus, which gave 
him some relief: the next day he threw up another. The first 
weighed a drachm, the second, half a drachm. Soon after 
this, he completely recovered. 

Case II. Dr. Camille Piron shewed me a woman who had 
all the symptoms, both local and general, of a scirrhous affec- 
tion of the pylorus ; which disappeared after she threw up a 
calculus the size of a nut, which had probably obstructed the 
pyloric orifice. It consisted almost solely of cholesterine. 

Case III.* A child eleven years old had from his infancy 
been subject to severe pains in the abdomen, and diarrhoea. 
He was lean, eat little, and was tormented with a burning 
thirst. In the right hypochondrium was felt a hard tumour, 
which seemed to belong to the liver. Vomitings set in, and 
the patient sunk. On opening the body, the intestine was 
found distended at the meeting of the ascending and trans- 
verse colon, by a calculous concretion, six inches in length, 
and twelve ounces and a half in weight. It was separated 
from the parietes of the intestine by a layer of thick mucus, 
and consisted of three portions, articulated, as it were, to one 
another. The first occupied the ascending portion of the in- 
testine ; another, the transverse ; and between them was the 
third, which was concave on one surface, and convex on the 
other. 

Case IV. f A young man, aged eighteen, eat during the month 
of June, 1814, a great quantity of green plums, and swallowed 
the stones. In a few months afterwards he began to feel pains 
in his belly, but not severe enough to prevent him from work- 



* Edinburgh Medical and Surgical Journal, July, 1825. Translated in the Ar- 
chives de Medecine, vol. xiv. page 254. 
t Archives de Medecine, vol. ii. page 148. 



BELOW THE DIAPHRAGM. 121 

ing. After some time they became more severe, and were ac- 
companied with an obstinate diarrhoea. On feeling the abdo- 
men, a hard circumscribed tumour could be discovered, which 
appeared to be an alvine concretion, but could not be expelled 
by any kind of medicine : the patient died in a state of maras- 
mus. On the body being opened, there were found, in the left 
portion of the transverse colon, three concretions united to- 
gether, and a fourth a little lower down, in the centre of which 
was a plum stone. 

Case V. * A woman, aged fifty, was attacked with a severe 
pain in the right hypochondrium. ■ Soon afterwacds, she pre- 
sented all the symptoms that indicate an obstacle to the free 
course of the fecal matter in the intestine ; such as hiccup, 
nausea, vomiting of stercoraceous matter, meteorismus, and 
rapid prostration of strength. These symptoms disappeared 
after the patient had passed by stool three calculi ; the first of 
which, in form, colour, and size, resembled a large chestnust, 
the second was as big as a pigeon's egg, and the third, which 
was triangular, and flattened, was of the same bulk as the 
second. They consisted in a great measure of cholesterine. 

In animals, also, similar effects have more than once been 
observed to result from the presence of a concretion in some 
part of the digestive canal. Thus, we have an account of a 
yearling calf, that died in a state of marasmus, and in whose 
second stomach, near the entrance of the oesophagus, was 
found an cegagropilus so situated as to impede the return of the 
food into the mouth, and thus prevent the act of rumination, f 



§ II. Morbid Secretions beneath the Mucous Membrane. 

Several alterations of secretion may take place without the 
mucous membrane, in the substance of its subjacent tissues, 
■especially the submucous cellular tissue. 



* Archives de Medecine, torn. xii. page 432. 
t Bulletin des Sciences Mediedtes, 1824. 

Vol. II. 17 



122 DISEASES OF THE ALIMENTARY CANAL 



FIRST GENUS. 



Effusions of Blood. 

There are sometimes found in the submucous cellular tissue 
more or less numerous ecchymoses, which may occupy from 
one or two lines to some inches in extent. They may occur 
with or without alteration of the portions of mucous membrane 
lying over them. The circumstances under which they appear 
are chiefly the following: — 

1. Some mechanical obstacle to the free passage of the blood 
from the branches of the vena portse to its trunk. 

2. Irritation of the alimentary canal. No one can doubt this 
who reflects that in men or animals poisoned by some corro- 
sive substance, ecchymoses of various degrees of number and 
extent have not unfrequently been found in different parts of 
the canal. 

3* Certain morbid states in which haemorrhages occur in all 
the tissues, in consequence of an alteration of the blood itself, 
whether spontaneous, or produced by external agents. In such 
cases, at the same time that the skin is covered with ecchymo- 
ses, they are also frequently found beneath the gastrointestin- 
al mucous membrane. This is what has been observed in the 
various diseases known by the name of scurvy, typhus, purpu- 
ra, hemorrhagica, morbus maculosus hcemorrhagicus Werl- 
hqfii, SfC 



SECOND GENUS. 

Exhalation of Serum. 

CEdema of the stomach or intestines is a disease that is not 
very uncommon. It is characterized by the existence of a cer- 
tain quantity of colourless and transparent serum in the areo- 



BELOW THE DIAPHRAGM. 



123 



lee of the submucous, subserous, and intermuscular cellular tis- 
sue. The quantity of serous fluid may be sufficiently great to 
increase the thickness of the gastro- intestinal parietes very 
considerably; and it may raise up the mucous membrane, 
either uniformly, or at intervals, so as to make it appear 
blistered. 

(Edema of the alimentary canal does not occur with equal 
frequency throughout : it is much more unusual in the stomach 
and small intestine than in the great ; and is sometimes the 
only lesion found in the colon of persons who have had a 
chronic diarrhoea. 

The mucous membrane investing the oedematous cellular 
tissue may be, 1. variously coloured ; 2. remarkably pale ; 3. 
more consistent and softer than usual ; and, 4. overspread with 
ulcers, or with numbers of follicles. 

As to the cellular tissue itself in. which the infiltration exists, 
it may either present no other alteration, or else it may be in a 
state of hypertrophy, thickening, and induration. In this case, 
we find some points where there is, if I may use the expres- 
sion, a dry induration of the tissue ; it grates under the scalpel, 
without yielding a drop of fluid ; in others, where the thickness 
of the tissue, its density, and its colour of a deader white than 
ordinary, indicate hypertrophy, we find considerable deposits of 
a serum that presents two remarkable varieties, being some- 
times purely aqueous, and sometimes, as if from a kind of ten- 
dency to become solid, being of a greater consistence, and re- 
sembling a more or less firm jelly. This is all that is observed 
in certain cases of induration of the gastro-intestinal parietes, 
termed scirrhous degenerations. It often happens that, at 
their circumference, where there is no induration, or trace of 
thickening of the cellular fibre, some serum is still found infil- 
trating the submucous tissues. 

There is another kind of serous exhalation, which sometimes 
occurs also in the substance of the gastro-intestinal parietes, 
but differs from the preceding in that the serum is con- 
tained in in a serous envelope that forms a regular cyst. 
This is usually of but inconsiderable size ; sometimes how- 



124 DISEASES OF THE ALIMENTARY CANAL 

ever the pouches of serous membrane larger than a hen egg 
have been found developed beneath the mucous membrane of 
the stomach. 



THIRD GENUS. 



Exhalation of Fat. 

No author, that I know of, has mentioned any case of the 
production of fat in the submucous cellular tissue. I once ob- 
served an instance of it, in which the mucous membrane at the 
upper part of the small intestine was raised up by a globular 
tumour of the size of a bean, and of a moderate consistence. 
The mucous membrane over it was not at all altered. The 
tissue of this tumour had all the characters of the adipose : it 
was situated wholly in the submucous cellular tissue. 



FOURTH GENUS. 



Exhalation of Gases. 

One of the frequent effects of putrefaction is the formation 
of gases in the substance of the gastro-intestinal parietes. 
When bodies are opened in summer ever so soon after four 
and twenty hours after death, the mucous membrane of the 
stomach and intestines is found puffed up in many places by 
gases accumulated in the subjacent cellular tissue. This em- 
physema is not, however, in all cases the result of cadaveric 
decomposition, but sometimes takes place during life. The 
case recorded by M. Jules Cloquet* is of this description. A 
scrofulous patient, twenty years of age, died at the Hopital St. 



* Bulletins de la FaculU de Medecine, vol. vii. page 267. 



BELOW THE DIAPHRAGM. 125 

Louis in the last degree of marasmus, in consequence of a ca- 
ries of the vertebral column. The body was opened shortly 
after death, before it had begun to show the least sign of pu- 
trefaction. There was considerable emphysema of the cellu- 
lar tissue that unites the different Coats of the stomach, so that 
its parietes appeared to have been inflated, and in several pla- 
ces were near an inch in thickness. The mucous membrane, 
which was embossed, was pale, and free from any appreciable 
lesion. The two anterior folds of the great omentum, which 
are attached to the great curvature of the stomach, were also 
separated from each other by gas, and the same was the case 
with the small omentum. There had been no symptom denot- 
ing any affection of the stomach, except a complete anorexia 
for several days before death. Similar gaseous exhalations 
have been seen in other portions of the submucous cellular tis- 
sue, especially in the substance of the parietes of the gall, blad- 
der. In laying before the faculty the case just cited, M. Clo- 
quet stated that he had often observed the same kind of em- 
physema in pigs recently slaughtered. In one of these, he 
found another very remarkable kind of emphysema : to the 
intestines and mesentery were attached in clusters large bun- 
dles of membranous vesicles, which were roundish, transparent, 
and filled with air ; they were each appended by a narrow 
thin vascular stalk. Their size varied from that of a pea to 
that of a small nut. 



FIFTH GENUS. 



Purulent Secretion. 

This is seldom observed in the substance of the gastrointes- 
tinal parietes. Sometimes, however, there are found beneath 
the mucous membrane, or between the scattered fibres of the 
muscular coat, collections of pus that are generally of small ex- 
tent. Sometimes there is but one, and sometimes several, 
more or less remote from each other. These abscesses, none 



126 DISEASES OF THE ALIMENTARY CANAL 

of which I have ever seen exceeding the size of a cherry, are 
more uncommon in the stomach than in the intestines. The 
pus contained in them is sometimes in a manner encysted, and 
sometimes merely infiltrated into the cellular tissue. In the 
latter case, it may be displaced, and extended into a layer of 
greater or less tenuity, by pressing on the mucous membrane. 
We must not confound these abscesses, which are genuine col- 
lections of pus in the cellular tissue, with other white tumours 
produced by follicles containing the same fluid. 

They have never appeared to me to produce any particular 
symptom ; and though they might discharge themselves through 
the mucous membrane or the peritoneum, they cannot have 
any connexion with either the purulent stools that occur in 
certain diseases, or the vomitings of pus reported by some to 
have been occasionally observed, and considered as arising 
from abscesses in the stomach. 

I once had an opportunity of observing in the parietes of the 
alimentary canal, a collection of pus, more extensive than 
those we have been considering, and also differently situated. 
In the case I allude to, the mucous membrane of the stomach 
was raised up through its whole extent by a layer of pus near- 
ly three lines in thickness, infiltrated into the submucous cellu- 
lar tissue. Beneath this layer the muscular coat was found 
uninjured. 



SIXTH GENUS. 



Melanic Secretion. 

A black colouring matter is occasionally deposited in the sub- 
mucous and subperitoneal cellular tissues, which in some cases 
gives them a uniform tint for a greater or less extent, and, in 
others, forms in one or more points small tumours projecting 
more or less considerably on either surface of the alimentary 
canal. 



BELOW THE DIAPHRAGM. 127 



SKVENTH GENUS. 



Tuberculous Secretion. 

This occurs pretty frequently in the substance of the pari- 
etes of the alimentary canal. Tubercles are very rare in the 
stomach, where I do not recollect having seen them more than 
twice ; they are more common in the small intestine, especially 
towards its lower part ; while in the great, they become rare 
again. They occur chiefly in three situations : 1. in the sub- 
mucous cellular tissue ; 2. in the lacerti of the muscular coat ; 
and, 3. in the subperitoneal cellular tissue. In all of these, 
they have the appearance of a small whitish tumour that raises 
up either the mucous or peritoneal membrane, through which 
their form and colour are perceptible. They vary in size from 
the bulk of a grain of millet to that of a pea. Sometimes there 
are but one or two found in the whole intestine, and some- 
times great numbers ; they are observed to be particularly nu- 
merous at the bottoms and margins of certain ulcers, especially 
those that occur in persons who have at the same time tuber- 
cles in the lungs. 

Tubercles may be found in pretty great numbers in the in- 
testines, after death, without having appeared to produce any 
serious symptoms with respect to the digestive passages. In 
some patients there has never been any diarrhoea ; in others, it 
has appeared only intermittingly ; and, lastly, in others, it has 
been constant. Therefore, when it does exist, it depends on 
other causes than on the presence of tubercles in the tissues 
subjacent to the mucous membrane. In like manner, pulmo- 
nary tubercles may exist a long time without being attended 
either with cough or any other thoracic symptom. 

The state, however, in which the mucous membrane is found 
over or around the tubercle, accounts for the variety of the 
morbid phenomena that have attended their existence during 
life. In fact, this membrane sometimes does not present any 



128 DISEASES OP THE ALIMENTARY CANAL 

appreciable kind of alteration ; sometimes it is merely injected, 
and the injection may have been intermittent like the symp- 
toms observed during life ; and, lastly, sometimes, whether in- 
jected or not, it presents various alterations which must have 
been constant, like the symptoms themselves. 

In the intestines, as every where else, the production of tu- 
bercles is the possible result of every cause that has a tendency 
to derange the natural process of nutrition and secretion that 
takes place in every living particle ; there too, as in every other 
part of the body, one of these causes may be irritation, whether 
acting primarily on the tissues subjacent to the mucous mem- 
brane, or propagated to them from it. We must not forget, 
moreover, that the source of the production of a submucous tu- 
bercle may have been a more or less intense irritation of the 
mucous membrane, even in those cases where there is no ap- 
preciable sign of any lesion found in that membrane after death. 
But while irritation of the mucous membrane is frequently the 
first element in the formation of intestinal tubercles, these, 
when once formed, may in their turn become a cause of irrita- 
tion to that membrane. Hence arises a new series of phenom- 
ena : the tubercles, acting like foreign bodies, produce by their 
presence the destruction of the superincumbent membrane, 
and the result is an ulcer through which the softened tubercle 
escapes, just as in the lungs it makes its way through an ulcer 
of the bronchia. 



ARTICLE IV. 

ENTOZOA OF THE ALIMENTARY CANAL. 

The entozoa that are found in the intestines of the human 
subject, belong either to the nematoidea or to the cestoidea. 



BELOW THE DIAPHRAGM. 129 

Those of the former class are three in number : namely, the 
ascaris lumbricoides, the trichocephalus, and the oxyuris. 

Those of the latter are two: the bothriocephalus and the taenia 
solium. 



I. Ascaris Lumbricoides. 



I have already given the anatomical description of this ento- 
zoon in the first volume. It resides most commonly in the small 
intestine, where it is sometimes found in great numbers in the 
dead body ; it is also found, though much more rarely, in the 
great intestine, stomach, oesophagus, and pharynx. These 
worms sometimes quit the alimentary canal, and make their 
way into different neighbouring parts. M. Blandin and I once 
found, at the Hopital des Enfans, an ascaris in the cavity of 
the larynx ; it occupied the space between the cordae vocales, 
and part of its body was still in the pharynx. The child had 
been suddenly attacked with extreme dyspnoea, and died very 
shortly afterwards in a state of asphyxia. M. Paul Guersent 
showed me a liver perforated in different directions by ascar- 
ides that seemed to have got into it from the duodenum through 
the ductus choledochus. I know of but one similar case, which 
is to be found in the 2nd volume of the Bulletins de la Faculte 
de Medecine de Paris. 

Ascarides have been known to pass through a perforation in 
the intestinal parietes into the peritoneum, and either continue 
there, escape through a fistula opening externally, or make 
their way into some other hollow organ, such as the bladder or 
vagina. 

It may be asked whether they can pass from the intestine 
into some other organ only by means of an accidental aperture 
which they find ready made, or whether they can make that 
aperture themselves? If the latter case ever happens, it is at 
least exceedingly rare. They .have sometimes been found ad- 
hering strongly by their oral extremity to the intestinal parietes; 
and it has been supposed that that was the commencement of 
Vol. II. 18 



130 DISEASES OP THE ALIMENTARY CANAL 

the process by which they make their way out. But if we re- 
flect that they cannot live any where except in the alimentary 
canal, we shall find reason to conclude that, even supposing they 
could perforate its parietes and so make their escape, the con- 
servative instinct would prevent their doing so. The case 
might, however, be different after the death of the animal in 
which they had existed ; as they might then have a much greater 
incentive to attempt their escape. Bremser mentions some 
facts on this head, which, although not relating to the human 
subject, deserve, I think, to be brought forward here. Some 
fishes that were put into vases of pure water, died after a few 
days. In one of them was found an echinorhynchus which had 
made a passage for itself not only through the parietes of the 
intestine, but also through the muscles and integuments. Brem- 
ser supposes that the creature, after the death of the fish in 
which it lived, had made its way out in search of food, but, 
not finding in the water either suitable nourishment or resi- 
dence, and perceiving, to use the author's own words, that it 
had arrived at the limits of its own world, had determined to 
re-enter; for it had evidently endeavoured to make its way 
back into a different part of the body from that through which 
it had got out. In others of those dead fishes, worms of the 
same kind had perforated the intestinal canal, and were found 
fixed, some to the internal parietes of the abdomen, and others 
to the external surface of the intestines.* 

We learn nothing from pathological anatomy respecting the 
causes which favour the production of these entozoa. They 
are found in every possible condition of the intestine, which 
may be indifferently red, or pale, dry, or abounding in mucus. 
Where there are numbers of them together, the surrounding 
portion of the intestine is often red, and the group which they 
form is frequently enveloped in a mass of mucus. In such 
cases, however, the increased vascularity of the intestine and 
the mucous secretion appear to be merely the effects of the 
presence of the worms, which then act like foreign bodies. 



* Traiti sur les vers intestinaux, by Bremser, 1 vol. 8vo. p. 351. 



BELOW THE DIAFHRAGM. 131 

Those pathologists who have endeavoured to explain the for- 
mation of intestinal worms, by attributing it to a peculiar de- 
gree or mode of intestinal irritation, and those who ascribe it 
to a state of weakness or want of tone in the alimentary canal, 
have alike given way to a favourite hypothesis. The fact is, 
that their formation depends on neither of these causes, but on 
some peculiar modification, the essence of which is unknown 
to us, but which appears to be specially produced under the 
influence of certain conditions, either inherent in the individual, 
such as constitution, age, &c, or external, such as food, par- 
ticular states of the air, &c To enter into particulars on this 
subject, would be foreign to the plan of this work. I shall only 
remark that in this case also, what we learn from pathological 
anatomy is very trifling in comparison to what we can discover 
by other methods of investigation ; since by it alone we could 
neither arrive at any rational theory of the formation of intes- 
tinal worms, nor discover the proper method of treatment. 



II. Tricho'ceplialus* 

This entozoon, which in organization resembles the preced- 
ing, is from an inch and a half to two inches in length. Its 
anterior extremity is much thinner than its posterior, as its 
name indicates, and terminates in an exceedingly fine point, 
so that the mouth is scarcely perceptible. The male is dis- 
tinguished from the female in this species, by the circumstance 
of its posterior extremity being spirally coiled on itself. Slen- 
der as the body is, there is found in it a straight alimentary ca- 
nal, surrounded by numerous spermatic vessels or oviducts. 

The trichocephalus resides principally in the caecum, and is 
generally found in great numbers ; like the ascaris, it is much 
more common in children than in adults. Rcederer and Wag- 
ler have found it in quantities in the great intestine. 



■. * This worm at first received the name of trichuris, its head having been mis- 
taken for its tail. 



132 DISEASES OF THE ALIMENTARY CANAL 



III. Oxyuris. 



This species is much shorter than the preceding, but some- 
what thicker: the male seldom exceeds from a line to a line 
and a half in length ; the female, which is larger, is four or 
five lines long. Its posterior extremity terminates in a point, 
whence it gets its name of oxyuris, instead of that of ascaris, 
by which it was formerly known. Its organization is the same 
as that of the ascaris lumbricoides and trichocephalus. 

The oxyuris has a special habitation, being found almost ex- 
clusively in the rectum, where it occurs sometimes in thous- 
ands: it is very common in children. 

Bremser doubts the accuracy of those cases mentioned by 
various authors of the oxyuris being found in other parts be- 
sides the great intestine ; though Bloch related a case in which 
worms of this species were contained in a cyst formed in the 
substance of the parietes of the stomach;* and Brera assures 
us that he found a great number of them in the oesophagus of a 
woman who died of a slow nervous fever. 



IV. Tcenia. 



This entozoon diners from the preceding in many respects, 
especially in its size, form, and organization. It is never less 
than several feet in length, and is sometimes many fathoms 
long. Vandoeveren has recorded the case of a person who 



* I have often found in the substance of the parietes of the stomach of the 
horse, hard tumours of a cellulo-fibrous texture, full of cells containing small 
white worms, very lively, some lines in length, and of a cylindrical form ; many 
of these had left the cells that seemed their habitual abode, and were spread over 
the internal surface of the stomach. Can these entoza have been the same that 
were seen by Bloch ? 



BELOW THE DIAPHRAGM. 133 

passed a portion of taenia one hundred and fifty feet long, and 
Rosenstein mentions another where it was three hundred. 

The taenia has a flat body, composed of a series of joints, 
each of which is provided with lateral pores. Its anterior ex- 
tremity, which is very delicate, terminates in a square head, 
furnished with four small suckers, between which appears, 
more or less plainly according to the species, a mouth or pro- 
boscis, surrounded by a crown of retractile hooks. 

The interior of the taenia presents only an amorphous cellular 
structure, without any trace of distinct organs. In fact the 
creature has merely the first rudiments of an alimentary canal, 
represented by a mouth or proboscis. Very distinct undula- 
tory movements have been observed in it. 

The taenia inhabits the small intestine ; sometimes, however, 
it has been found in the stomach. There may be several in 
in the same person. Unlike the preceding species, which exist 
principally in children, the taenia occurs most frequently in 
adults. It is found much more commonly in the dog than in 
man, and, apparently, is not productive of any inconvenience 
to that animal ; for I have frequently found enormous taaniaj in 
the intestines of dogs that had been sacrificed to physiological 
experiments, while appearing to enjoy perfect health. 

In man, there are two species of taenia. The first is the 
tenia armata, also called tenia solium, tenia longannulata, and 
tenia cucurbitina. It is the detached joints of this worm that 
have received the name of vermes cucurbitini. Towards the 
head, it is no more than a quarter or a third of a line in breadth- 
lower down it becomes so broad as six lines. Its head is fur- 
nished with hooks; and, of the two free margins of each joint, 
one only is provided with a pore. 

The other species of taenia is known by the name of tenia 
lata, tenia mermis, and bothriocephalic*. This generally is in 
fenor to the other in length, but its breadth is greater; each of 
its joints , s shorter, and provided with a pore at each side, 
which last ,s one of the best characters to distinguish it from 
the tenia solium. Its head is not furnished with hooks. 



134 DISEASES OF THE ALIMENTARY CANAL 



ARTICLE V. 



STATE OF THE ALIMENTARY CANAL IN THE DIFFERENT CASES 
WHERE ITS FUNCTIONS ARE DERANGED. 



We have now reviewed all the alterations of the alimentary 
canal that pathological anatomy can discover to us by the pres- 
ent means of investigation. If each of these alterations invaria- 
bly produced during life a determinate group of well marked 
symptoms, we could easily tell what had occurred before death, 
from the appearances observed after it; but such is by no 
means the case: for of all the parts of the body, the alimentary 
canal is tliat in which identity of lesions least infers identity of 
symptoms either local or general. Having premised these few 
observations, we shall now attempt to answer the following 
question: Given the different groups of symptoms to which 
particular names have been assigned, what is the state of the 
alimentary canal after death in each case ? 

The greater number of the functional derangements to which 
the alimentary canal is liable, have been of late referred to a 
state of irritation of the part, indicated in the dead body, 1. by 
various degrees of sanguineous congestion; and, 2. by various 
alterations of nutrition and secretion. According to the portion 
affected, the assemblage of symptoms has been designated by 
the names of gastritis, enteritis, colitis, gastro-enteritis, entero- 
colitis, duodenitis, dothi-nenteritis, fyc. These expressions may 
be adopted, provided we consider them only as provisional 
terms, the use of which is to suggest to the mind certain alter- 
ations, of which irritation is the common connecting link, or 
occasional cause, but which, at the same time differ widely in 
their nature and causes, as well as in the functional derange- 
ments they produce, and the treatment they require. I shall 
now proceed to examine each functional derangement sepa- 



BELOW THE DIAPHRAGM. 135 

rately, and inquire to what anatomical condition of the alimen- 
tary canal it corresponds. 



j. I. State of the Alimentary Canal in its various functional 
derangements. 

These derangements may be classed as follows: 

Class I. Modifications of hunger and thirst. 

Class II. Modifications of the phenomena of chymification- 
dyspepsia. 

Class III. Modifications of the phenomena of secretion and 
excretion. 

Class IV. Modifications of sensibility. 



FIRST CLASS. 



Modifications of Hunger and Thirst. 

The sensation of hunger may be either increased (bulimia), 
diminished (anorexia), or perverted (pica). We are now to 
inquire what is the state of the alimentary canal in each of 
these cases. 

Bulimia has been attributed by some authors to particular 
lesions, such as an unusual dilatation of the pyloric orifice, the 
opening of the ductus choledochus into the stomach, too abun- 
dant secretion of the gastric juice, the stomach being larger 
than natural, or the intestine shorter ; and, lastly, to the pres- 
ence of worms in the alimentary canal. These lesions have in 
most cases been admitted as causes of bulimia, rather from 
theory than from actual observation, but in this, as indeed in 
almost all theories, some valuable facts have been observed and 
recorded. Thus, in a case of a galley-slave remarkable for his 
voracious appetite, Vesalius asserts he ascertained that the bile 
flowed directly into the stomach. Tarara, a celebrated glut- 
ton, whose history has been given by M. Percy, had a stomach 



136 DISEASES OF THE ALIMENTARY CANAL 

of enormous size ; and Cabrole tells us that, in a person who 
was continually tormented with insatiable hunger, he found an 
enormous stomach, terminating in an intestine which, from the 
place where the pylorus usually exists, to the anus, was only 
three feet long. However, it may be fairly questioned wheth- 
er the unusual size of the stomach in great eaters, instead of 
being the primary cause of hunger, is not rather the effect of 
the great quantity of food they are in the habit of introducing 
into it. 

Bulimia may be produced by a state of irritation of the 
stomach. It occurs in certain forms of chronic gastritis; but 
in these cases no sooner is the least quantity of food introduced 
into the stomach, than total anorexia succeeds to the importu- 
nate craving which the patient had previously felt. Many per- 
sons labouring under chronic, gastritis experience an uneasiness 
or sensation of dragging in the epigastrium, which they are apt 
to mistake for hunger. 

Bulimia may be completely independent of the state of the 
stomach, being connected with an habitual or temporary ex- 
cess of activity in the general nutritive process. Thus, it is 
frequently observed at the period of puberty, in children when 
growing rapidly, in convalescents, and lastly, in pregnant 
women ; so that we have here one of the thousand instances of 
the necessity of seeking the cause of a functional derangement 
at a distance from the organ whose function is affected. 

Anorexia is the most constant attendant on all the different 
morbid alterations of the stomach already described. There 
are some serious affections of that organ, such as considerable 
softening, ulceration, and induration of the submucous cellular 
tissue, which do not give rise to any other symptom ; whilst on 
the other hand, cases have more than once been observed of 
circumscribed lesions of the stomach where the appetite was 
not at all diminished. Lastly, in some persons, who had for a 
length of time the greatest aversion to every kind of food, I 
have not been able to find in the stomach any lesion that could 
account for it : M. Louis has recorded several cases of the same 
description. 



BELOW THE DIAPHRAGM. 137 

Anorexia may, like bulimia, have its cause in other parts 
besides the stomach. It occurs during the course of most 
acute and chronic diseases. Modifications of the nervous in- 
fluence' are likewise a frequent cause of anorexia ; for we 
know that a moral emotion, or a strong intellectual exertion, is 
sufficient to produce a sudden suspension of the appetite. 

Muscular fatigue, when carried to excess, also produces the 
same effect. In these various cases, a modification of the in- 
nervation changes the regular action of the stomach, as it does 
that of the skin, kidneys, liver, &c. 

There are certain states of the system in which most of the 
actions of the life of relation become suspended, the secretions 
either cease altogether, or are greatly diminished, and several 
weeks may elapse without the introduction of any food into the 
stomach. Such a state occurs naturally every year in hiber- 
nating animals. It is probable that, in this singular condition, 
the process of nutrition of the organs is also suspended, whence 
the possibility of the creatures doing without food for a very 
long time ; so that here also the modification of the functions of 
the stomach is only an effect of the modification impressed on 
more general functions, whose integrity is necessary to the 
due accomplishment of those of that organ. Thus, by virtue 
of the consensus of all the living parts, the functions of assimila- 
tion can only continue perfect so long as the stomach digests 
properly ; and the stomach can digest properly, only so long 
as there is no derangement in the various functions whose bus- 
iness is to supply or assimilate the nutritive matter to the dif- 
ferent tissues. 

Pica may likewise occur as a symptom of chronic irritation 
of the stomach ; but, in general, it would be vain to seek for 
the cause of it solely in the state of that viscus ; it occurs chief- 
ly in certain morbid states, where both the blood and the nerv- 
ous system have been primarily modified : in such cases, hys- 
terical, chlorotic, or pregnant females, take a pleasure in eating 
chalk, as they do in breathing fetid effluvia ; and certainly no 
one would take upon himself to assert that a girl in whom the 
catamenia are irregular has a coryza, because a smell that is 
disgusting to every one else, is eagerly sought after by her. 
Vol. II. 19 



138 DISEASES OF THE ALIMENTARY CANAL. 

From what has been said it appears that the cause of all the 
different modifications of hunger may reside either, 1. in the 
stomach itself; or, 2. out of that organ in the different tissues 
for which the stomach prepares the matter to be afterwards 
assimilated by them ; or lastly, in the nervous system, or in 
the blood ; the modifications of either of which necessarily pro- 
duce modifications of every vital action. 

The modifications of thirst may likewise be referred to the 
same causes. This affection is often symptomatic of gastric 
irritation ; it is also frequently the result of some abundant 
evacuation which has deprived the blood of its proper quantity 
of serum. Thus, an ardent thirst occurs after abundant per- 
spirations, and generally attends on diabetes. It is, then, far 
from being proved that a person labouring under fever is affect- 
ed with gastric irritation because he feels great thirst; he may 
be thirsty merely because his blood contains too little serum, 
which is perhaps the origin of the thirst, as well of the whole 
diease. It may be said, that this is all hypothesis ; but it must 
be allowed, that it is equally hypothetical to assert that in such 
cases the origin of the fever is in the stomach, because the pa- 
tient is thirsty and his tongue is red. I would ask, is it also 
necessarily the stomach that reddens the conjunctiva and in- 
jects the skin, in those cases 1 



SECOND CLASS. 



Modifications of the Plwnomena of Chymification. 

It is now useless to set about proving that dyspepsia, in all 
its forms, may be the result of gastric irritation. This has 
been already demonstrated by M. Brussais, and undoubtedly 
one of the most valuable services he has rendered the science 
of medicine, is his having taught practitioners to treat and cure 
by anti-phlogistics a great many forms of dyspepsia which were 
formerly attributed to a weakened state of the stomach. But 
yet, it may fairly be questioned, whether every case of dyspep- 



BELOW THE DIAPHRAGM. 139 

sia necessarily results from gastric irritation. The practice of 
most French physicians of the present day would apparently 
authorize our answering this question in the affirmative ; but 
at every period of medical science we find the practice regu- 
lated by the prevailing theory, and its efficacy proved by its 
successful results. It is, however, perfectly well ascertained 
that some cases of dyspepsia, which had resisted the anti-phlo- 
gistic treatment, yield readily to other remedies that are any 
thing but debilitating. And it is equally well ascertained, that 
in persons who have long suffered from indigestion, the stom- 
ach often presents no anatomical lesion sufficient to account 
for it ; and even in those cases where lesions of the stomach 
are found, it is by no means clear that they have been produced 
by irritation. If we proceed to investigate the symptoms 
which attend on this lesion, we find that there are some which, 
when combined and strongly marked, appear to be so little the 
result of irritation, that they are advantageously treated, nay, 
speedily removed, by means that are themselves irritating. 

Thus, whether we consider the appearances found after 
death, the symptoms presented during life, or the results of the 
different methods of treatment, we arrive at the conclusion, 
that there are several kinds of dyspepsia, each of which indi- 
cates a peculiar state of disease, and requires a particular mode 
of treatment. 



FIRST GENUS. 



Dyspepsia from Gastric Irritation, acute or chronic. 

This is, beyond all contradiction, the kind of dyspepsia most 
commonly met with. 



140 DISEASES OF THE ALIMENTARY CANAL 



SECOND GENUS. 



Dyspepsia from Weakness of the Stomach. 

This is observed to occur, 1. under the influence of causes 
altogether unknown ; and, 2. subsequently to certain apprecia- 
ble modifications of the system. Thus, it sometimes happens 
that the stomach, after having been more or less irritated, falls 
into the opposite state, and becomes affected with genuine 
atony. The same happens in some cases of convalescence. 
This state of atony likewise occurs in persons exhausted by 
excess in venery, and, still more, by onanism. It would be a 
serious mistake in such cases to imagine that dyspepsia is al- 
ways the result of gastric irritation ; for that would lead to the 
employment of remedies which frequently aggravate the com- 
plaint. Under such circumstances, I have seen dyspeptic af- 
fections yielding rapidly to a tonic regimen, which could not 
have failed to exasperate the irritation of the stomach, if such 
there had been. Why may there not be weakness of the stom- 
ach as well as of the mucles in those cases ? Dyspepsia from 
weakness of the stomach is generally attended with a com- 
plete absence of thirst, and great paleness of the tongue. The 
patient experiences, after taking food, a sensation of weight 
in the epigastrium, and frequently a tension in the same region. 
The use of gum water sometimes produces these symptoms, 
as do also the infusions of linden and chamomile, though in a 
less degree. This particular state of the stomach may render 
the pulse somewhat more frequent ; but, as we have already 
seen more than once, frequency of the pulse is not necessarily 
connected with a state of irritation. 



BELOW THE DIAPHRAGM. 141 



THIRD GENUS. 



Dyspepsia from Alteration of the Follicular Secretion of the 
Stomach. 

There is a peculiar morbid state of the stomach that has long 
been distinguished by French practitioners by the name of 
" embarras gastrique," the nature of which is far from being 
well known. It is characterized by a certain assemblage of 
symptoms, local and general, does not yield at all to blood- 
letting, and but slowly to diet, while it readily gives way to emet- 
ics and purgatives. That the symptoms which attend this af- 
fection are often connected with irritation of the stomach, and 
that they are then exasperated by tartar emetic, has been 
proved by experience ; but that it is, in every instance, merely 
gastritis, and not a disease of another kind, and requiring a 
mode of treatment as peculiar as the symptoms that announce 
it, is a conclusion totally incompatible with observation. 

It may be presumed that one of the causes of this affection 
is an alteration of the mucous secretion of the stomach, and I 
do not see why such an alteration should be considered as ne- 
cessarily the result of irritation, unless we choose to allow that 
the mucous coating that sometimes covers the tongue necessa- 
rily indicates glossitis. 



FOURTH GENUS. 



Dyspepsia from Modification of the Nervous Influence. 

We know that the process of chymification may be modified 
by deranging the innervation of the stomach either by admin- 
istering opium, cutting the pneumogastric nerves, or producing 
a strong mental emotion. In these various cases, the digest- 



142 DISEASES OF THE ALIMENTARY CANAL 

ive powers are not so much increased or diminished, as per- 
verted from their natural condition. Certain cases of dyspep- 
sia seem likewise to result from this modification of the nervous 
influence. Against these, antiphlogistics and tonics are equally 
unsuccessful, and the reason is evident ; for the indication of 
cure is neither to weaken nor to excite the stomach, but to 
modify its action. 



THIRD CLASS. 



Modifications of the Phenomena of Secretion and Excretion. 

We have here to study the state of the alimentary canal, 1. 
in the different kinds of vomiting ; 2. in the various kinds of 
diarrhoea ; and, 3. in cholera morbus, in which disease there 
are evacuations both upwards and downwards. 

Most of the anatomical lesions already described as occur- 
ring in the stomach appear after death, without there having 
been any vomiting during life ; but at the same time there is 
not one of these lesions of which it may not be a symptom. 

The causes of vomiting may reside either in the alimentary 
canal itself, or in some other part of the body. 

In the first place we find vomiting produced by all possible 
degrees of irritation of the gastric mucous membrane, which 
cause the patient either to throw up his food and drink, or else 
the bile that had previously been attracted by the irritation into 
the stomach ; in other cases the matter vomited consists of 
blood exuded by the irritated mucous membrane, or of mucus 
secreted in superabundant quantity; which last, by accumu- 
lating, becomes a kind of foreign body, and produces by its 
presence a secondary irritation more considerable than that to 
which it owed its existence. Many persons discharge from 
their stomachs every morning a certain quantity of mucus se- 
creted at night ; is this daily vomiting, as has been lately main- 



BELOW THE DIAPHRAGM. 143 

tained by M. Rene Prus,* the cause of certain cases of hyper- 
trophy of the muscular coat of the stomach, that are taken for 
cancerous degenerations of that viscus? And do we, by stop- 
ping the vomiting, destroy the efficient cause of the hypertro- 
phy, and prevent its occurrence? Such is the opinion of 
M. Prus, and he recommends opium for the purpose of putting 
a stop to the unusual secretion of the mucous membrane of 
the stomach, or gastrorrhcea, as it may fairly be termed. f 

The most common effect of the introduction of an irritating 
poison into the stomach is to produce vomiting, which contin- 
ues long after the poison has been thrown up ; and yet in the 
different varieties of fever, which M. Broussais considers as so 
many cases of acute gastroenteritis, this symptom is observed 
but very seldom. 

Other causes, which produce vomiting more frequently than 
irritation itself, are the various mechanical obstacles to the free 
passage of the contents of the alimentary canal situated either 
in the stomach near its orifices, or in some other part of the 
canal. These obstacles may either be formed suddenly, as by 
swallowing a foreign body, and by various kinds of internal and 
external strangulation; or gradually, by the thickening of the 
parietes of the canal, by the accumulation of faecal matter, or 
by the formation of calculous concretions, &c. 

Irritation of the serous coat of the stomach is often a cause 
of vomiting, independently of any alteration in the mucous 
membrane itself. Indeed nothing is more common than to 
find it white and healthy in persons dying of acute peritonitis, 
who had been continually vomiting to the last moment of their 
lives. 



* Op. cit. 
1 1 lately tried the method of M. Prus upon a patient at La Charite who had 
for a long time been affected with frequent vomitings of a transparent fluid resem- 
bling a strong solution of gum arabic. I gave him, for about a month, from one 
to six grains of the watery extract of opium daily, which stopped the vomitings, 
and restored the functions of the stomach, though the ordinary effect of the med- 
icine is to derange the digestive powers. 



144 DISEASES OF THE ALIMENTARY CANAL 

The causes of vomiting that do not exist in the alimentary 
canal, must be sought for specially in the nervous centres. 
That a modification of the nervous system is sufficient to pro- 
duce attempts at vomiting, without the stomach being at all 
concerned, is a fact that cannot be doubted after the experi- 
ments of M. Majendie. This physiologist ascertained that if 
we remove the stomach of an animal, substitute in its place a 
pig's bladder, and then introduce tartar emetic into the veins, 
we soon observe the animal becoming sick, attempting to vomit, 
and, if the bladder has been properly placed, absolutely vom- 
iting. 

The vomitings owing to a modification of the nervous influ- 
ence, are of many kinds. Some are produced by the action 
of that conservative instinct that tends to repel every thing 
that might hurt the system : thus, the mere sight of disgusting 
objects is sufficient to cause sickness, and sometime even vom- 
iting. Another example of vomiting produced in this way is 
to be found in the retching caused by sea sickness, by the tick- 
ling of the uvula, and by the arrival of the fecundated ovum into 
the cavity of the uterus. Is it not also the nervous influence 
that is the primary source of the copious vomitings which of- 
ten occur in nephritis? Lastly, in diseases of the brain, one 
of the most striking symptoms observed is vomiting, even when 
the stomach is found after death in a perfectly sound state. 
Such vomitings as those, that do not leave any trace of lesion 
in the stomach, frequently mark the commencement of acute 
hydrocephalus, continue during its whole course, and end only 
with life. 

I think we may conclude from these facts that, in the present 
state of the science, the expression nervous vomiting deserves 
to be retained, as signifying a real morbid state, in which the 
gastric symptoms that occur have their source not in the stom- 
ach itself, which is not materially altered, but in the brain, 
whose texture or action is decidedly modified. One of the 
most striking instances of these nervous vomitings is that re- 
corded by M. Louyer Villermay: the subject was a woman, 
who, in consequence of a disappointment in love, was attacked 
alternately with globus hystericus, dyspnoea, and palpitation ; 



BELOW THE DIAPHRAGM. 145 

she uttered involuntary cries, and at last was seized with vom- 
itings, which were treated in vain by the antiphlogistic method 
{diet, emolient drinks, leeching). She was at last cured by the 
vinum absinthii, and the first food she digested was hard boiled 
eggs and salad. 

The various intestinal fluxes known by the name of dysen- 
tery, diarrhoea, and lientery, are not constantly connected with 
any peculiar state of the alimentary canal. 

It is true that, in the greater number of cases, we find in the 
intestines of persons who have had any kind of looseness, va- 
rious alterations, of which the primary cause and common 
connecting link is a process of irritation, past or present. 
These alterations exist most frequently in the great intestine, 
of which they sometimes occupy the whole, and sometimes 
only a part. There are some cases where the caecum, and 
others, where the rectum alone is diseased. The small intes- 
tine may continue sound through its whole extent; and one is 
sometimes struck with the abruptness with which the morbid 
state commences immediately below the ileo-ceecal valve. In 
other cases, on the contrary, there is no sign of any lesion to 
be found in the great intestine, and the end of the ileum is the 
only part diseased. The most common case is that in which 
the inferior extremity of the ileum and a more or less exten- 
sive portion of the great intestine are simultaneously affected. 

These alterations, which have been all described already, 
from simple injection to ulceration and perfect softening, bear 
no constant proportion, either to the duration, or the symptoms 
of the disease. Thus, in several persons who have had a diar- 
rhoea for the same space of time, from eighteen months to two 
years, for instance, and in whom the disorder has been attended 
with the same series of phenomena, local and general, there 
may be found in one a simple red or brown hyperaemia, with- 
out any other alteration ; in another, a red softening of the mu- 
cous membrane ; in a third, a white softening of the same ; in 
a fourth, induration with various shades of colouring ; in a fifth 
an unusual developement of the follicles, without any other le- 
sion ; in a sixth, ulcers of various sizes, and in various num- 
bers ; and lastly, in a seventh, some one or other of the above- 
Vol. II. 20 



146 DISEASES OF THE ALIMENTARY CANAL 

mentioned alterations of the mucous membrane, together with 
various morbid states of the subjacent tunics, such as thicken- 
ing, serous infiltration, &c. As to the symptoms, there is not 
one that announces with certainty that the intestine is affected 
with one particular lesion rather than another. Thus we find 
the same alterations where there has been a serous and bilious 
diarrhoea, as where there has been dysentery. There is not 
unfrequently complete absence of fever and of pain, in those 
cases where the intestine is crowded with ulcers, and the mucous 
membrane is greatly thickened, and of a red, brown, or black 
colour. 

Does dissection discover, in the bodies of all who die while 
affected with intestinal flux, some one of the alterations just 
mentioned ? This has been asserted, but the assertion is not 
supported by facts. The researches of modern anatomists 
have clearly proved, that there are certain cases in which dis- 
section cannot discover any appreciable alteration either in the 
colour, thickness, or consistence of the intestinal parietes, or 
the appearance of the follicles, &c. In some of these cases the 
diarrhoea commenced only a few days before death, and in oth- 
ers had been of a long standing. Here, then, is another case 
where the appearance of the alimentary canal after death does 
not lead to any certain knowledge of the functional derange- 
ments with which it had been affected during life. 

Lastly, there are some diarrhoeas that are owing to a morbid 
secretion which is not formed in the alimentary canal, but 
which escapes from the body by that outlet. Thus, in certain 
cases of copious bilious diarrhoea, we cannot, on dissection, dis- 
cover any thing in the intestine but an enormous quantity of 
bile, beneath which the mucous membrane is quite free from 
any alteration, being scarcely injected ; while the source of the 
disease is the liver, as it is also in certain cases of constipation. 
We see, then, that every unusual influx of bile into the intes- 
tine is not necessarily the result of a primary irritation of that 
part itself. Other organs, again, that are near the alimentary 
canal, may form an accidental communication with some part 
of it, and pour into it various secretions, natural or morbid. I 
saw three cases in which the ovaries poured out pus into the 



BELOW THE DIAPHRAGM. 147 

rectum through a perforation, and thus produced a constant or 
intermittent purulent diarrhoea.* 

The disease known by the name of cholera morbus, in which 
abundant evacuations take place upwards and downwards at 
the same time, is another striking instance of the difficulty we 
often experience in judging solely from the appearance of or- 
gans after death, how they have been affected during life. 
Though the terrible symptoms that accompany this disease 
would appear to be connected with some very serious lesions 
of the intestinal canal, yet we only find on dissection a greater 
or less degree of vascular injection, such as is frequently found 
in other cases, where there had been no considerable affection 
of the stomach or intestines during life. I have but once seen 
the post mortem examination of the body of a person that had 
died of cholera morbus, and that was in a case where the dis- 
ease had lasted five days. The mucous membrane of the great 
extremity of the stomach exhibited a fine red dotting ; but in 
the rest of the stomach it was hardly injected, and was of the 
usual consistence and colour throughout. There were a good 
many arborescent injections on the internal surface of the two 
lower thirds of the small intestine, whose parietes had no where 
lost their transparency ; the caecum was of a greyish tint, and 
the rest of the great intestine was but slightly injected. The 
liver, spleen, and lungs were gorged with blood. 



FOURTH CLASS. 

Modifications of the Sensibility. 

Severe pain seldom accompanies any of the various altera- 
tions of texture of the gastro-intestinal mucous membrane. It 



* A very interesting case of this description has been published by M. Dal- 
mas, in the Journal Hebdvmadaire de Mtdecine, for November, 1828. 



148 DISEASES OF THE ALIMENTARY CANAL 

may be injected, softened, thickened, or deeply ulcerated, with- 
out the patients' complaining of any uneasy sensation ; or, at 
most, they feel some griping pains on going to stool. This is 
the case not only in the chronic, but also in the acute state of 
these lesions. We may in general press the abdomen in all di- 
rections, in persons labouring under severe fever, and whose 
intestines are considerably ulcerated. It is only when the ul- 
cers extend in depth, so that their bottom is composed of the 
peritoneal membrane, that severe pain is felt. 

While the most serious alterations in the texture of the gastro- 
intestinal mucous membrane produce little or no pain, there are 
other cases in which the alimentary canal becomes the seat of 
very severe pain without its texture being at all altered; as in 
the disease known by the name of colica pictonum, or saturnine 
colic. Some writers have asserted that in cases of this affec- 
tion they found, on dissection, the caliber of the intestines re- 
markably diminished ; others, again, that the symptoms arose 
from introsusception ; and lastly, others, that in persons who had 
died of the disease, the intestine was found more or less inject- 
ed, and that, consequently, this disease was a species of enteritis. 
It is very possible that there may have been found, in the intes- 
tines of persons who died of saturnine colic, diminution of cal- 
iber, introsusceptions, or various degrees of redness; but all 
these lesions seem to me to be merely accidental, since, on the 
one hand, they may occur without producing the symptoms of 
colica pictonum, and, on the other, they are not invariably found 
in persons who have died of the disease. I have related else- 
where* in detail several of these cases in which I was not able 
to discover any appreciable lesion in the alimentary canal. 
M. Louis has related others of the same description. Neither 
could I, in a single case, discover any lesion of the nervous cen- 
tres, and yet there had been remarkable paralysis in most of 
them. 

It is not merely persons exposed to the influence of lead that 
present the various symptoms whose assemblage constitutes 



CUnique Medicali 



\ 



BELOW THE DIAPHRAGM. 149 

colica pictonum: the same symptoms are observed, 1. in per- 
sons who have been exposed to sudden and repeated variations 
of temperature ; as in the colic of Madrid ; 2. under the influ- 
ence of causes that act primarily on the nervous system; and, 
3. without any known cause. In the last two cases, the dis- 
ease gets the name of nervous colic. 

During the last campaign in Spain, there were several op- 
portunities of examining the bodies of persons that had died with 
all the symptoms of the colic of Madrid. Dr. Pascal* has pub- 
lished an account of six dissections'of this kind made by him- 
self; and the result is, that in the colic of Madrid, as in the sat- 
urnine colic, the lesions of the alimentary canal are neither seri- 
ous nor constant. Thus, he found a redness of the intestine, 
and that but slight, in three of the cases. The brain seemed in 
its natural state in all ; he always found the spinal cord injected ; 
in one case it was softer than natural for a space about two 
inches long. He also examined the great sympathetic, and 
assures us he found several of its ganglions injected, and their 
consistence somewhat altered. While praise is due to M. Pas- 
cal for his useful researches, we must wait for further observa- 
tions to confirm their results. 



§ II. State of the Alimentary Canal in Fever. 



The term fever must have been one of the first employed in 
medical language. It is purely metaphorical, and was used at 
first merely to express some of the more prominent symptoms 
of the disease. When the skin felt hot, and the pulse beat with 
increased force or frequency, the state of the system was ex- 
pressed by borrowing a term that gave some idea of the dis- 
ease; *»pe|«s of the Greeks,/e&m of the Latins: and the whole 
practice then consisted in opposing to this burning fever, medi- 
cines called temperative, or cooling. 



* Memoire de M. Pascal in the Journal de Medecine Militaire. 



150 DISEASES OF THE ALIMENTARY CANAL 

It was soon observed that, during the course of fever, besides 
the general symptoms that characterize its presence, various 
others often appeared that denoted an affection of some organ 
in particular; this was considered one of the effects of the fever 
produced by its exerting its virulence chiefly on that particular 
part, or, as the common people still say, fastening upon it; 
hence the terms pneumonic, pleuritic, cerebral, gastric, rheu- 
matic fever, &c. 

During this second period, the fever was still considered the 
cause of all the organic lesions that occurred during its course; 
but this theory was gradually modified, and many lesions which 
were at first considered the effects of the fever, came subse- 
quently to be considered as its cause. When this reformation 
was effected, the fever was in a number of cases regarded 
merely as a symptom ; the names of the diseases were modi- 
fied, the terms pneumonia, pleurisy, &c, being substituted for 
those of pneumonic, pleuritic fever, &c. ; and the term fever 
was restricted to certain morbid states, characterized by fre- 
quency of the pulse, heat of the skin, and a general derange- 
ment of the functions, without any evident local origin. It was 
supposed that in such cases the cause of the fever resided in it- 
self, and hence Galen termed it essential fever. However, 
the different morbid states thus denominated were far from 
being similar ; and it was therefore necessary to admit several 
kinds of essential fevers, which received various names, taken 
sometimes from their supposed causes, (such as nervous fever, 
bilious, mucous, putrid, milk, camp, hospital, gaol fever, &c.) 
and sometimes from their spmptoms, (such as inflammatory, 
malignant, putrid, typhoid, petechial, pestilential, yellow, hec- 
tic, &c). The mention of these various names is sufficient to 
shew that the names given to the so called essential fevers had 
no fixed basis, and varied continually with the theories of the 
day. 

In default of some organic alteration that could be regarded 
as the local origin of fever, its proximate cause was at one time 
supposed to be a morbific matter which was to be eliminated 
by the fever ; at another, an obstruction, against which the 
heart reacted ; sometimes it was attributed to spasm of the 



BELOW THE DIAPHRAGM. 151 

nerves, sometimes to a spontaneous alteration of the blood, and, 
lastly, to a modification of the general excitability, whether 
consisting simply in its augmentation, or in its diminution sub- 
sequent to its augmentation. 

Even to the present day many authors have continued to ap- 
ply the term fever to many of the inflammations of organs ; 
and it is by that name they are still described in the Traite de 
Medecine Practique of Hildenbrand. Pinel, in his Nosographie 
Philosophique, established a perfectly distinct class of these in- 
flammations, in which fever was only considered one of the 
symptoms, and retained the denomination essential fevers, to 
signify certain general morbid states in which there is nothing 
to be observed but a quickening of the pulse, heat of the skin, 
and general derangement of the functions. He agreed with 
Galen in considering this morbid state as essential, that is to 
say, capable of existing independently of any local lesion. 
However, strange to tell, while Pinel thus admitted the exist- 
ence of essential fevers in his Nosology, he attributed them to 
local causes in his list of synonyms. Thus, he placed the in- 
flammatory fever of authors in the apparatus of circulation, by 
calling it angeio-tenic fever; he allowed that in bilious fever 
the gastro-intestinal mucous membrane is particularly affected, 
since he called it meningo- gastric fever ; he attributed mucous 
fever to the intestinal follicles, by calling it adeno-meningean ; 
and, lastly, he established positively that ataxic fever is seated 
in the nervous system. As to the adynamic fever, he consider- 
ed it merely the expression of a symptom. We must observe 
that in the whole of this classification he attributes no part to 
the fluids, but shows himself an exclusive solidist. 

Pinel's classificaton of essential fevers was necessarily tem- 
porary : it is evidently the product of the constantly increasing 
tendency among physicians, from the time of Galen, to the lo- 
calization of fevers. In fact, one of the problems whose solu- 
tion has most constantly occupied them, may be thus stated : 
given an assemblage of symptoms, to find their cause in the al- 
terations of some solid or fluid. In Pinel's classification, or 
rather in his list of synonyms of essential fevers, all is not new; 
he was not the first that appreciated the great influence of the 



152 DISEASES OF THE ALIMENTARY CANAL 

alimentary canal in the production of many of them. Most of 
the authors who had previously devoted their attention to 
pathological anatomy, had pointed out the alterations found in 
the canal in such cases, much better than he did ; and in this 
respect he is to blame for not having sufficiently profited by 
the labours of his predecessors. Do we not find in Bonetus : 
Anatome eorum qui febre maligna extincti sunt, docet ventri- 
culum cum intestinis inflammari ; and in Bartholinus : In ornni 
febre acuta imminet ventriculi inflammatio ? Again, Sydenham 
has repeated in several parts of his works, that the intestines 
become ulcerated in continued fevers ; and Roederer and 
Wagler, in their history of the mucous fever of Gottingen, have 
given an admirable description of the alterations of the follicles, 
and the ulcers, &c, that were found on opening the bodies of 
those that sunk under it. 

None of these authors, however, has maintained positively 
that the lesions they discovered in the alimentary canal were 
the cause of the essential fevers ; some regarding them as an 
effect of the fever, or as a complication, and others allowing 
them only a part in the production of certain symptoms. Prop- 
erly speaking, this is all that Pinel has done too ; but still, in 
his writings, as in those of his predecessors, there is a constant 
tendency to the localization of fevers. Such was the state of 
science when M. Broussais came to effect a happy change in 
this department of pathology. The ideas of this eminent Pa- 
thologist are now so widely disseminated, and have been so 
generally adopted, that it would be quite useless to describe 
them here ; to examine them, and decide upon their merits, is 
all that we shall need to do. 

To seek, in the alteration of one or more parts of the body, 
the seat and the cause of the fevers called essential ; to consider 
them as merely the symptoms of a local affection more or less 
manifest; and to direct the treatment against that affection, 
and not against the fever itself, which is merely an affect, are 
parts of the doctrine of M. Broussais which have already pro- 
duced a most extensive and important revolution in medical 
science. These tenets, however, form but a part of his doc- 
trine : he has also attempted to specify the lesion which alone, 



BELOW THE DIAPHRAGM. 158 

in his opinion, can give rise to the various symptoms that char- 
acterize essential fevers, and he maintains that all such fevers 
are the result of gastro-intestinal irritation. Here he has failed ; 
and while I agree with him that every kind of fever may be 
attributed to a local source, I think that the localization should 
not be at all so confined as he has made it. On this head, the 
following propositions appear to me to give a pretty accurate 
idea of the present state of our knowledge with respect to the 
seat and nature of fever. 

There is no essential fever, so called, which may not be 
refered to the alteration either of some solid or of the blood, 
as its cause. These essential fevers, then, are not general dis- 
eases, inasmuch as they have always a local origin; but they 
may be considered general in this sense, that, being sometimes 
seated on the nervous centres, or in the blood, they produce a 
disease all over the body, wherever the blood and nerves are 
distributed, or, in other words, a general disease. 

With respect to their local origin, fevers may be divided into 
three classes ; the first consisting of such as arise from a pri- 
mary alteration of the nervous centres; the second, of those 
arising from the lesion of a solid; and the third, of those arising 
from a modification of the blood. 

The fevers belonging to the first class are distinguished by 
that assemblage of symptoms which M. Pinel has assigned to 
adynamic and ataxic fevers, especially the latter. The former, 
however, more frequently occurs when the disorder of the ner- 
vous centres is subsequent to an affection of the alimentary 
canal, or some other part. Although the symptoms of those 
fevers plainly point out their seat during life, dissection some- 
times discovers no more alteration in the nervous centres than 
in the other organs. In my opinion, this absence of alteration 
does not affect the determination of the seat of the disease; that 
having been too clearly indicated by the derangement of the 
functions to be mistaken. Will any one assert that epilepsy or 
tetanus is a general disease, because he cannot discover any 
lesion in the bodies of persons who have died of either? 

Fevers of the second class depend on the primary alteration 
of a solid; this alteration may be, 1. in the quantity of blood it 
Vol. II. 21 



154 DISEASES OP THE ALIMENTARY CANAL 

receives; 2. in its texture; or, 3. in its functions only. The 
solid primarily affected is certainly in a large proportion of 
cases the alimentary canal, but it may also be the skin, lungs, 
liver, kidneys, heart, vessels, uterus, ear, prostate, &c. 1 have 
mentioned these different parts, because I am in possession of 
facts that prove that the alteration of any one of them, without 
any concomitant lesion of the alimentary canal, is capable of 
giving rise to the symptoms that constitute the different essen- 
tial fevers. The tongue, in some of those cases I allude to, 
was red, in others thickly coated, and in others dry and black, 
and yet on dissection there was no lesion discovered either in 
the stomach or intestines. 

In these various cases, we are far from being always able to 
establish a constant proportion between the intensity of the 
lesion, and the nature of the symptoms that constitute the fever; 
as they depend much less on the severity of the local lesion, 
than on the state of the innervation and sanguification that 
happens to exist in the individual in whom the lesion occurs. 
In fact, on this circumstance it depends whether the slightest 
lesion may not occasion a most serious ataxic or adynamic fe- 
ver; and a much more severe one produce only inconsiderable 
symptoms. 

Adynamic fever, which is so often occasioned by these va- 
rious lesions, is a complex term comprehending several morbid 
states differing greatly with respect to their nature and proper 
treatment. It is often merely the result of a considerable op- 
pression of the vital powers, produced by a local lesion. But, 
frequently also, when the lesion occurs, the nervous centres 
have scarcely reacted before they fall into a real state of col- 
lapse, and in this case the adynamic condition is genuine; the 
nervous influence by which every organ lives has really lost its 
energy; and throughout the whole body life is less active, and 
the resistence to the return of the organized being to the do- 
minion of the laws of physics is less strong; we have here a 
genuine adynamic state produced by an increase of vitality in 
some part of the body. In such cases it may happen that along 
with the signs of prostration of strength we observe some symp- 
toms of cerebral excitement ; but such symptoms are only 



BELOW THE DIAPHRAGM. 155 

factitious, as the adynamic state is in other cases. We must 
therefore beware of supposing that subsultus tendinum, con- 
vulsions, and delirium, are always signs of increase of celebral 
life: they are so far from being necessarily so, that they some- 
times occur after abundant haemorrhages. 

Lastly, the third class of fevers appears to be more particu- 
larly connected with alterations of the blood. On this head, I 
can but refer to what I have already said in the first volume, 
when treating of the diseases that may arise from that source. 
I shall content myself at present with repeating that the fever 
termed inflammatory, seems to me often to arise from no other 
source than the blood's being too rich in fibrine ; in like man- 
ner an impoverished state of the blood, whether accidental or 
natural, is often connected with mucous fevers, and with those 
characterized by a sudden sinking of vital powers : the blood's 
not being sufficiently depurated is certainly the cause of the 
fever termed urinous, and probably that of certain bilious fe- 
vers also ; lastly, the source and primary seat of typhus fevers, 
properly so called, is proved to be in the blood, inasmuch as 
they are caused by the introduction of deleterious substances, 
such as animal or vegetable effluvia, into that fluid. 



§ III. State of the Alimentary Canal in the Diseases of the va- 
rious Organs. 



It has long been known that the alimentary canal is one of 
the organs that most readily influence the diseases that may be 
situated in other organs ; as also that its affections may be the 
source of a great many functional derangements of different 
organs. 

In every ten cases of acute disease not arising from the ali- 
mentary canal, there are about eight in which is observed a 
greater or less derangement in the texture or functions of that 
part. 

In chronic diseases, whatever be their nature, it is very sel- 
dom indeed that the alimentary canal does not undergo some 



156 DISEASES OF THE ALIMENTARY CANAL 

alteration. This is sometimss permanent, and is then chronic, 
like the disease with which it is complicated ; in other cases it 
is only temporary, and there may be either one, or several at- 
tacks of it. The gastro-intestinal irritation that occurs thus 
intermittingly may produce no effect on the primary chronic 
affection ; but the reverse frequently happens. There are 
cases, for instance, in which, whenever the irritation of the di- 
gestive passages re-appears, the chronic affection is exasperated, 
and has a tendency to return to the acute state ; there are 
others in which, on the same occasion, the old affection, so far 
from being exasperated, is so much amended that its symptoms 
become much less apparent. Lastly, in many cases, whether 
the primary chronic affection be unaltered, aggravated, or re- 
lieved, the gastro-intestinal irritation produces another effect : 
it acts on the innervation, and produces in the patient exhausted 
by long disease that assemblage of symptoms that character- 
izes the adynamic fever of Pinel. Under such circumstances, 
a slight irritation of the alimentary canal is sufficient to pro- 
duce a great and sudden prostration of strength. Many per- 
sons affected with a chronic disease that has long been under- 
mining the constitution, sink thus under an adynamic fever 
arising from a trifling congestion in the alimentary canal. The 
danger of such a hypersemia is not so much in proportion to its 
intensity, as to the diathesis of the patient at the time it occurs. 

There are certain cases of hypersemia of the mucous mem- 
brane of the air passages that are accompanied by a similar af- 
fection of the mucous membrane of the alimentary canal, which, 
being spread over a great surface, is but slight in any one point. 
The diseases known by the names of inflammatory, mucous, 
and catarrhal fevers, are often merely an effect of this general 
congestion of the two mucous membranes. 

Whenever either of these membranes is the seat of chronic 
irritation, it is very seldom that the other does not also become 
affected. The alimentary canal is so habitually diseased in 
persons affected with tuberculous bronchitis, that such disease 
is in a mariner one of the elements of phthisis, and almost 
makes a constituent part of it. In about four-fifths of the 
phthisical patients that die at an advanced period of the com- 



BELOW THE DIAPHRAGM. 157 

plaint, the intestines are found greatly diseased ; the lesion most 
frequently observed is ulceration, the ulcers being generally 
situated at the end of the small intestine, where they some- 
times, though not always, attack Peyer's glands, and in the cae- 
cum. They are very variable in number, form, and size, and 
are most commonly formed without any pain, producing mere- 
ly a more or less abundant diarrhoea. From the very com- 
mencement of phthisis it is not unusual to observe slight signs 
of intestinal irritation ; there are often alternations of consti- 
pation and of diarrhoea, which last gradually becomes perma- 
nent, like the lesion that produces it. 

The stomach in consumptive patients is also affected, but 
the alterations it presents are of another description : there are 
usually neither ulcers nor tubercles found in it ; but its mucous 
membrane is very often softened, and the whole of its parietes 
frequently attenuated.* 

What is the cause of the dyspepsia or of the pains in the stom- 
ach experienced by many women affected with leucorrhea? 
Do they suffer merely from simple gastric irritation ? Is the 
morbid modification that takes place in their stomach, of the 
same nature as that which the utero-vaginal mucous membrane 
has undergone ? If the alteration of secretion that takes place 
in the latter is often removed only by treatment that is any 
thing but antiphlogistic, are we to employ the same treatment 
to relieve the stomach 1 There is still some light wanting on 
this subject : however, as it is always advantageous to the 
cause of science to publish facts for the accuracy of which we 
can answer, I shall state briefly the following case. A woman 
was admitted at La Charite with a leucorrhoea of long stand- 
ing, difficulty of digestion, and a pain in the region of the stom- 
ach. I prescribed leeches to the epigastrium, without effect ; 
and opiates were found equally unsuccessful. I then tried 



* The different ways in which the stomach and intestines may be affected in 
phthisis pulmonalis exert a great influence over the symptoms and progress of 
the disease. On this head, I could but repeat here what I have already said in 
my CUnique Medicate, to which I refer the reader. 



158 DISEASES OP THE ALIMENTARY CANAL 

pills of extract of bark and iron filings, whereupon the pain in 
the epigastrium diminished, and digestion was restored. 

Cutaneous affections are accompanied as frequently as those 
of the various mucous membranes by a diseased state of the 
prima vice. In persons that die of extensive burns, the ali- 
mentary canal is generally found of an intensely red colour. 
Every one knows that in many cases of erysipelas, the stom- 
ach is affected at the same time ; and it is also known that this 
affection, which is by many physicians considered to me owing 
to the presence of bile in the stomach, has been often relieved 
by emetics. It has been said that, by employing such med- 
icines, the gastric symptoms are removed, the erysipelas is ren- 
dered milder, and its extension or renewal prevented. Theo- 
retically, I do not see any absurdity in the supposition that the 
presence of an unusual quantity of bile or mucus in the stomach 
may produce erysipelas. It is well known that muscles, when 
eaten, sometimes produce nettlerash. Judging from ex- 
perience, what may be said on the practice of administering 
emetics in erysipelas is this : 1. they are injurious when the 
tongue is red, and the thirst great, &c. ; 2. they have no effect 
either way in many cases where there are no evident signs of 
gastric affection ; 3. they are really useful where the patient 
has a bitter taste in his mouth, the tongue covered with a thick 
white or yellowish coat, without any redness beneath or 
around it, fetid eructations, nausea, &c. ; in such cases, I have 
known the employment of emetics remove these symptoms, 
and the erysipelas have a favourable and speedy termination. 
Whatever theory we adopt, we must admit these facts. 

At the commencement of the febrile exanthemata, there is 
almost constantly a congestion of one of the mucous mem- 
branes ; and it is not one of the least remarkable circumstances 
in the history of these diseases, that, in each of them, the same 
portion of membrane is always affected : in scarlatina, it is the 
mucous membrane of the pharynx ; in the measles, that of the 
air passages ; and in small pox, that of the stomach. Before 
the eruption of this last disease, the gastric membrane gen- 
erally presents only a slight irritation, which diminishes rather 
than increases when once the eruption begins to appear. But, 



BELOW THE DIAPHRAGM. 159 

in some cases, this precursory irritation is very severe, and 
either continues after the commencement of the eruption, which 
then comes out very badly, or diminishes or even ceases alto- 
gether, as soon as the eruption begins to appear. 

The gastro-intestinal irritation, though slight at the com- 
mencement, may become much more intense during the course 
of the disease ; and in many cases where the small pox is 
termed putrid, malignant, adynamic, &c. it is merely com- 
plicated with a more or less severe gastroenteritis, which, on 
the one hand, has modified the eruption, and on the other, has 
re-acted on the nervous centres. When the disease proves 
fatal, there are found in the alimentary canal the various altera- 
tions already described, from hypersemia to ulceration. Are 
there also found in it pustules similar to those that cover the 
skin ? Since they are observed very distinctly on the mucous 
membrane of the cheeks, there is no reason why they should 
not also occur on the portion of the membrane situated lower 
down. But, though in theory the existence of variolous pus- 
tules in the intestine is admissible, they have never yet been 
seen there. The mucous follicles, more developed than ordi- 
nary, have often been taken for them ; such a mistake is par- 
ticularly easy in children, in whom these follicles are often very 
large. 

The chronic exanthemata are attended with a state of irrita- 
tion of the digestive passages much less frequently than has 
been asserted. I require no other proof of this than the ease 
with which persons affected with various chronic affections of 
the skin support, at the hospital Saint Louis, under the care of 
M. Biett, the most irritating medicines, which that able practi- 
tioner knows how to employ so happily. 

If we direct our attention to certain organs that may be re- 
garded as appended to the alimentary canal, we shall find that 
they can hardly be diseased without its either having been so 
previously, or subsequently becoming so. In how many cases, 
for instance, are the affections of the liver connected with a 
morbid state of the intestines. It is the same with the mesen- 
teric ganglions, and almost every time that they are found dis- 
eased in the dead body, we either find traces of intestinal irri- 



160 DISEASES OF THE ALIMENTARY CANAL 

tation also, or else learn from the symptoms, that such irrita- 
tion had existed at a period more or less remote from the time 
of the examination. 

One of the most important services which M. Broussais has 
rendered to medicine, was the proving that, in many cases 
where, from the functional derangements, one would suppose 
the nervous centres were alone affected, the origin of the dis- 
ease is really to be found in an irritation of the alimentary 
canal. This is true of all ages, particularly of infancy. In 
childeren it frequently happens that, after coma, convulsions, 
&c. there is no morbid appearance to be discovered in the 
brain, while the alimentary canal is evidently diseased. 

A great many functional derangements of the nervous cen- 
tres have been referred to irritation of the digestive tube, be- 
cause the intestines have frequently been found diseased in 
cases where such derangements had existed. Thus, it has 
been asserted that tetanus, epilepsy, chorea, apoplexy, and 
alienation of mind, result from gastroenteritis. In my opin- 
ion, there is not a nervous disorder that may not be developed 
in consequence of an irritation of the alimentary canal, as well 
as of any other part; but then a previous disposition to it is 
requisite. 

On the other hand, the nervous centres, when primarily 
affected, often ^exercise as great an influence over the alimen- 
tary canal as it does over them ; but the influence is not always 
of the same kind : sometimes, for instance, irritation of the 
brain produces in the stomach a hypersemia demonstrable by 
dissection, and sometimes an excitement indicated by the de- 
rangement of its functions, but not discoverable by the anat- 
omist. Thus it often happens, as we have already remarked, 
that we cannot discover any lesion in the stomach of persons 
who have been affected with copious vomitings in conse- 
quence of acute hydrocephalus. Lastly, in other cases, dis- 
eases of the brain affect the alimentary canal with a kind of 
torpor, so that emetics and purgatives do not produce any 
effect. 



ABOVE THE DIAPHRAGM. 161 



SECTION II. 



DISEASES OP THE PORTION OF THE ALIMENTARY CANAL ABOVE 
THE DIAPHRAGM. 



The infinitely varied forms assumed by these alterations have 
all been included by modern anatomists under the three gen- 
eral terms, stomatitis, pharyngitis, and oesophagitis ; but these 
denominations are often insufficient or inaccurate. It is true 
that these alterations have, as a common element, a san- 
guineous congestion preceding, or, at least, accompanying 
them ; but, in many cases this is neither their sole nor their 
chief cause, and in none can its various degrees of intensity 
serve to explain the nature or degree of the alterations pro- 
duced. Thus, it would be committing a strange mistake to 
suppose that ulcers of the mouth and pharynx, the false mem- 
branes that line their surface, and gangrene of the same parts, 
are connected with an intense congestion : they are so far 
from being so, that the local signs of irritation that precede 
them, and the sympathetic functional derangements they pro- 
duce, are often much less marked than those that accompany 
the most simple erythema of the mucous membrane of the 
mouth or pharynx. But, ever, though the numerous lesions in- 
cluded under the common name of stomatitis or pharyngitis 
appear frequently to be idiopathic, and to depend solely on a 
local process of irritation, either spontaneous or produced by 
the application of some stimulating substances, there are other 
cases in which such lesions are merely some of the secondary 
symptoms of a disease affecting simultaneously other solids, or 
even the whole mass of the blood. Thus, in persons that have 
Vol. II. 22 



162 DISEASES OP THE ALIMENTARY CANAL 

long been breathing an impure, damp air, and living on bad 
or not sufficiently nutritive food, and in whom we have every 
reason to think that the blood is more or less altered, we often 
find the mucous membrane of the cheeks gorged with a thin 
blood that oozes out through the parietes of its vessels ; we find 
it softening, ulcerating, and becoming gangrenous. In such 
cases it sometimes happens that, without any pain or antece- 
dent hyperemia, a grey or black spot appears in some part of 
the mouth, extends rapidly, and in a few hours the whole of 
the mucous membrane of the cheeks is reduced to a putrid 
mass. Towards the end of certain chronic diseases, or during 
the course of an acute disease in persons of a feeble constitu- 
tion, and habitually deficient in blood, it is not uncommon to 
see the internal surface of the mouth coated with a whitish, 
pulpy layer, which increases as the vital powers diminish, and 
disappears if they return. Even admitting that in such cases 
this morbid secretion results sympathetically from gastrointes- 
tinal irritation, we must acknowledge that it is a peculiar effect 
of it ; since every degree of such irritation may occur without 
the secretion being observed, and, on the other hand, be the 
degree what it may, the secretion appears under particular 
conditions of innervation and sanguification. Whatever be 
the way in which we suppose the syphylitic virus to exist, still 
it is true that, in a longer or shorter period after impure coition, 
we but too frequently observe the different portions of the 
stomato-pharyngean. mucous membrane eaten up by ulcers ; 
and, in this case, it is very evident that they are only one of 
the symptoms that indicate the general alteration of nutrition, 
just as it may at the same time be indicated by various lesions 
of the skin, osseous system, &c. Again, introduce mercury 
into the system, aud you will behold effects more or less re- 
sembling those already mentioned. In such cases we observe, 
as a constant and primary lesion, an alteration of the blood, 
which becomes like that of scorbutic persons ; and, as con- 
secutive lesions, various alterations of nutrition, amongst others, 
lesions of the mouth analogous to those observed in scurvy : 
and it is a remarkable fact, that the slightest irritation accident- 
ally offered to the mucous membrane of the cheeks, which 



ABOVE THE DIAPHRAGM. 163 

under any other circumstances would only produce a trifling 
erythema, is in these cases sufficient to cause the most serious 
derangement in that membrane. Thus, in certain individuals, 
we observe a tubercle or a cancer occasioned by the slightest 
inflammation. 

From those considerations we may infer that many of the 
diseases of the mouth are only accidental or necessary mani- 
festations of a morbid state originating elsewhere; and conse- 
quently, that, in this case, as in many others, the disease is not 
confined to that part where organic lesion can be detected; 
that there is often a great difference between discovering the 
true nature of the disease, and being aware of the existence of 
such lesion; and, lastly, that it would in many instances be 
either useless or dangerous to attempt to combat the lesion by 
purely local treatment. 



CHAPTER I. 

Accidental Lesions of that Portion of the Alimentary Canal 
situated above the Diaphragm. 



ARTICLE I. 

LESIONS OP THE MOUTH AND PHARYNX. 

I have nothing particular to say concerning the various de- 
grees of hyperemia, softening, and induration, that may be 
presented by the stomato-pharyngean mucous membrane; as 
they resemble those I have already described in detail, when 



164 DISEASES OF THE ALIMENTARY CANAL 

treating of the stomach and intestines. This membrane, how- 
ever, presents some other alterations that are peculiar to itself, 
which must consequently be here described. Of this nature, 
particularly, is the kind of affection lately described by M. Bre- 
tonneau under the name of diphtheritis, which is merely an 
acute hypersemia of the mucous membrane of the mouth and 
pharynx, followed by a membraniform exudation that an- 
nounces the peculiar nature of the disease, since it is certain, 
that this remarkable morbid production cannot be accounted 
for either by the intensity or the duration of the sanguineous 
congestion that precedes and accompanies it. In this, as in a 
thousand other cases, hypersemia is one of the elements of the 
disease; but it is not its sole constituent: accordingly, as we 
learn from M. Bretonneau, diphtheritis does not yield to blood- 
letting, while, notwithstanding the train of inflammatory symp- 
toms that accompany it, its progress is arrested by stimulating 
substances, such as hydrochloric acid, alum, and chloride of 
lime. Now, how do those agents act; is it by subduing irrita- 
tion? Surely not; for their effect would rather be to in- 
crease it. But perhaps it will be said that one irritation is sub- 
stituted for another: the assertion is merely hypothetical; and 
even granting it to be true, there should be as frequently, or 
even more frequently, exasperation as amendment of the dis- 
ease ; which is not the case. We must acknowledge, then, that 
by this more or less stimulating treatment we modify that un- 
known disposition by virtue of which the morbid secretion takes 
place ; and the hypersemia is a secondary symptom produced 
by the same cause that gives rise to the membraniform exuda- 
tion. 

However, the hyperemia, though secondary with respect to 
casuality, is the first symptom that appears in diphtheritis; as, in 
a gland, the afflux of blood to the part precedes the secretion 
of the fluid, though the particular nature of the secreted fluid 
can in no wise be accounted for by the different degrees of 
abundance of that afflux. The first symptom we observe in 
dipththeritis is a number of red dots or streaks scattered over 
the surface of the mucous membrane, which does not in general 
present any remarkable degree of tumefaction. Sometimes, 



ABOVE THE DIAPHRAGM. 165 

however, from the very outset of the disease, the surrounding 
cellular tissue is congested, and the submaxillary lymphatic 
ganglions are considerably swelled. The red appearance of 
the membrane is, after a longer or shorter interval, succeeded 
by a set of white spots, which are at first isolated, and seem to 
exist chiefly on the follicles, but afterwards multiply, enlarge, 
touch, and at last run together so as to form a uniform layer of 
greater or less extent: sometimes there are several patches; 
and sometimes there is only one, which covers a vast space, 
and is continually extending itself. The thickness of this layer 
is variable ; it is occasionally thin enough to be in some degree 
transparent. One of its surfaces is free; the other, which ad- 
heres to the mucous membrane, presents a great many pro- 
cesses that dip into the mucous follicles. Its colour is generally 
white, but it is sometimes greyish and soiled by the blood ex- 
haled by the mucous membrane, which gives it an ashy tint, 
that, together with the extreme fetor of the secretion, has often 
caused such patches to be taken for sloughs of the mucous 
membrane. At other times, patches of small extent, and lying 
lower than the surrounding tumid mucus membrane, have been 
mistaken for ulcers. 

From the mouth and pharynx, these membraniform patches 
may extend to the air passages, oesophagus, or nasal fossae ; they 
may also occupy simultaneously the external auditory duct, 
and the temporal surface of the concha; and, lastly, as if 
wherever a process of irritation was produced it had a tenden- 
cy to terminate in a similar secretion, we observe those parts 
of the body that have been blistered, and in general all denud- 
ed surfaces, covered with a pseudo-membranous layer more or 
less analogous to that in the interior of the mouth and pharynx. 

With respect to its consistence, the layer presents several 
varietes, being pulpy, caseiform, or like lard. It may be situ- 
ated beneath the epithelium, or lie naked on the mucous mem- 
brane. When detached, it may or may not be renewed seve- 
ral times. All those varieties should, in my opinion, be con- 
sidered merely as different shades of the same disease. 

The tissues subjacent to the stomato-pharyngean mucous 
membrane do not escape its disorders. For instance, we often 



166 DISEASES OP THE ALIMENTARY CANAL 

observe the cellular tissue that enters into the composition of 
the parietes of the mouth or pharynx, becoming affected. In 
the first place, it not unfrequently becomes the seat of a consid- 
erable afflux of blood, causing a sudden tumefaction of the 
part ; as is exemplified in the cheeks in those diseases termed 
defiuxions. It is also by a similar accumulation of blood in its 
cellular tissue that the tongue sometimes acquires, in a very 
short space of time, such an enormous bulk, as to stop up the 
posterior part of the mouth, considerably obstruct the passage 
of the air, and project beyond the lips. This tumefaction of 
the tongue, which may be complicated with haemorrhage from 
its surface, is evidently the result of congestion, as it is readily 
put down by deep incisions. It sometimes occurs intermit- 
tingly. In place of blood, it is sometimes serum that infiltrates 
the cellular tissues. Such serous congestions have been ob- 
served in the tongue, but are still more frequently seen in the 
uvula, which then acquires a kind of transparency, increases 
singularly in size, and interferes with the deglutition. This 
cedema of the uvula may be idiopathic, connected with some va- 
rieties of cynanche, or attendant on induration of the tonsils. 
Pus may also exist in this cellular tissue, either generally dif- 
fused or in the form of an abscess ; it is most frequently 
found in the substance of the cheeks, gums, and tonsils, and 
sometimes occurs also in the substance of the tongue. 

This same cellular tissue, when it has undergone a chronic 
alteration in its nutrition, becomes thickened, indurated, and at 
the same time infiltrated with an albuminous fluid that con- 
cretes, and unites with it ; in this way, the lesion termed scir- 
rhous degeneration, is produced. At the same time that the 
cellular tissue becomes thus developed and indurated, the sur- 
rounding tissues (by virtue of a law I have elsewhere proved) 
often have a tendency to atrophy, becoming less and less dis- 
tinct, and at last disappearing altogether, leaving nothing behind 
them but a hard homogeneous mass of a white or greyish col- 
our. In a person whose disease was termed scirrhus of the 
tongue, that organ, which was increased in size, and remarka- 
bly hard, presented merely a whitish tissue, resembling the in- 
durated cellular tissue around old cutaneous ulcers, and con- 



ABOVE THE DIAPHRAGM. 167 

taining some scattered vestiges of muscular fasciculi, which 
were thin, colourless, compressed, and almost effaced. 

Of the numerous follicles that open on the surface of the 
stomato-pharyngean mucous membrane, those whose assem- 
blage forms the tonsils are subject to several morbid alterations 
that deserve a particular description. The seat of these alter- 
ations is sometimes in the cellular tissue situated between the 
follicles, which may either be simply congested, secrete pus, or 
become indurated and enlarged, thus producing the so called 
scirrhous state of the tonsils. At other times it is the follicles 
themselves, as well as the lacunae into which they open, that 
are altered either in the texture of their parietes, or in the fluid 
contained in their cavities. Their parietes, like those of every 
other follicle, are found, according to the case, either in a state 
of simple hyperasmia, or of hypertrophy, induration or soften- 
ing. The fluid naturally secreted by them may be modified 
in its quality, so as to become either pus, or a concrete friable 
substance like tubercle, or one still more solid, of sufficient 
consistence to be termed a calculous concretion, and varying 
in size from the bulk of a grain of millet to that of a kidney 
bean. These various morbid secretions seem to be contained, 
sometimes in a single lacuna considerably enlarged, and some- 
times in a cavity formed by the accidental union of several. 
These facts are not merely interesting from the situation of 
the parts affected, but also from the light they throw on the 
nature of the alterations of texture of other portions of the mu- 
cous membranes, in which accidental cavities containing pus, 
tuberculous matter, or calculous concretions, seem likewise to 
be merely follicles altered in the structure of their parietes, 
and in the qualities of their secretion. 

Hypertrophy of the tonsils may exist unattended by indura- 
tion: it is frequently accidental, but is sometimes congenital. 
It generally becomes a permanent cause of irritation to the 
neighbouring mucous membrane, thus producing frequent sore 
throats. Here, then, is an instance of the developement of a 
tissue beneath a mucous membrane being a cause instead of 
an effect of an acute or chronic irritation of that membrane. 
The overgrown tissue here acts in a manner as a foreign body. 



168 DISEASES OP THE ALIMENTARY CANAL 

It is, perhaps, also worthy of remark, that in many persons 
whose tonsils thus present an excess of developement (a dispo- 
sition known to be hereditary) we likewise observe a bad con- 
formation of the thorax, and other characters of the scrofulous 
diathesis: so true is it that in this case, as in many others, a 
slight and circumscribed modification of nutrition, affecting an 
insignificant organ, depends on the most serious modifications 
in the whole of the nutritive process.* 

Gangrene of the mouth and pharynx has been long consid- 
ered a common affection ; but recent researches have shown 
the inaccury of such an opinion. It is beyond all doubt that 
the greater number of cases of gangrene of those parts de- 
scribed by old authors should be referred to certain varieties of 
stomatitis or pharyngitis, attended with formation of greyish 
false membranes. However, we must not fall into an opposite 
error, and deny the existence of such gangrene altogether. It 
is quite certain that it has more than once been known to suc- 
ceed an acute irritation of the stomato-pharyngean mucous 
membrane. In other cases, the gangrene seems to be almost 
the primary affection; without .any of the usual premoni- 
tory symptoms, there appear in one or more parts of the 
mouth or pharynx, spots of a brownish red, which soon be- 
come black, extend more or less rapidly, and change into 
sloughs of variable size and depth. This gangrenous affection 
of the mouth has been more frequently observed in children 
than in adults. Even among children, it is scarcely ever met 
with except in those of the poorer classes, that have been 
dwelling in damp, dark habitations, and living on unwholsome 
or not sufficiently nutritive food ; or in such as have a highly 
scrofulous constitution, or shew symptoms of scurvy. This 
affection sometimes attacks individuals that are free from any 
acute disease, and sometimes, those that are labouring under 
gastro-enteritis, or some cutaneous eruption, such as small-pox, 



* A great many diseases undoubtedly originate in purely local lesions ; but the 
severity of those lesions, the symptoms to which they give rise, their various ter- 
minations, and even the modifications produced in them by the treatment em- 
ployed, all depend on the state of the whole system at the time. 



ABOVE THE DIAPHRAGM. 169 

measles, or scarlatina. It may attack the mucous membrane 
only, which it then destroys to a greater or less extent, extend 
its ravages to the subjacent tissues, or even involve the whole 
of the soft parts that enter into the composition of the parietes 
of the cheeks, and thence proceed to the periosteum and the 
bones. When the disease arrives thus far, the teeth already 
grown fall out, the roots of the second set are also destroyed, 
and, if the patient recover, he probably remains toothless the 
rest of his life. At the same time the child grows remarkably 
pale; its cheeks become cedematous, its whole body wastes 
rapidly away, the pulse becomes small and wretchedly feeble, 
the skin cold, and if the progress of the gangrene be not ar- 
rested, death speedily follows. Some authors see in all this 
train of symptoms nothing but stomatitis terminating in gan- 
grene. But, if it be true that this gangrene occurs chiefly under 
certain morbid conditions of the innervation and sanguification, 
and if, moreover, its appearance is not preceded by any per- 
ceptible inflammatory reaction, should we not, in this case also, 
consider the affection of the mouth to be connected with a 
morbid state that is not confined to the part where the gan- 
grene appears? In like manner, in those cases where the use 
of rye affected with ergot, as an article of food, is followed by 
gangrene of the inferior extremities, the cause of the gangrene 
is not to be found in those extremities. 

Writers have described, under the name of glossanthrax, a 
variety of gangrene of the mouth affecting the tongue. It com- 
mences by the appearance, in some parts of the tongue, of a 
vesicle filled with a bloody serum, which is at first livid, but 
soon becomes black, breaks, and beneath it the gangrene ex- 
tends more and more, and may even involve the whole of the 
organ ; when the disease attains this height, symptoms of ner- 
vous prostration set in, and death speedily ensues. Glossan- 
thrax has sometimes been met with in man, but has been chiefly 
observed in horses living on watery food and in damp situa- 
tions. It has been ascertained that, at the same time that this af- 
fection raged among numbers of horses that were placed under 
the circumstances above described, others that inhabited the 
same country, but were not exposed to damp, and were sup- 
Vol. II. 23 



170 DISEASES OP THE ALIMENTARY CANAL 

plied with good provender, escaped. It has also been frequently- 
found, in horses, that the gangrene of the tongue was attended 
with gangrene of other organs. 

Ulceration occurs as a common, but not a necessary termi- 
nation of the various alterations of the mouth and pharynx that 
we have been considering. Sometimes its appearance is pre- 
ceded by a simple hyperemia of the mucous membrane, which 
subsequently becomes softened and eaten away in a circum- 
scribed point; sometimes it succeeds a vesicle or pustule ; and 
in some cases it occurs as the termination of a diphtheritic or 
gangrenous irritation. Ulcers in this situation present nothing 
worthy of remark, beyond what I have already pointed out in 
my description of ulcer of the infra-diaphragmatic portion of 
the canal. 



ARTICLE II. 



LESIONS OF THE OESOPHAGUS. 



The oesophagus much less frequently undergoes any morbid 
alteration than the mouth and pharynx, and still less so than 
the stomach and the other parts of the infra-diaphragmatic por- 
tion of the alimentary canal. 

The epithelium, which covers its mucous membrane, is some- 
times eroded, softened, and destroyed, especially in the inferior 
part of the oesophagus. In some cases I have found the epithe- 
lium remarkably thickened. 

The mucous membrane of the oesophagus presents the same 
alterations as in the other parts of the alimentary canal. It is 
but seldom affected with hyperaemia. It is sometimes thick- 
ened, either generally or in patches. Vegetations of various 
forms and sizes are sometimes found shooting up from its in- 



ABOVE THE DIAPHRAGM. 171 

ternal surface, narrowing the passage, and offering a greater 
or less obstruction to the act of deglutition. Ulcers are sel- 
dom found on this portion of the mucous membrane.. There is 
a case recorded of the parietes of the oesophagus being found 
agglutinated by a plastic matter secreted by the mucous mem- 
brane, in a person that died of small pox. 

In the oesophagus, as in the rest of the alimentary canal, the 
submucous cellular tissue sometimes becomes indurated, thick- 
ened, and transformed either into a scirrhous tissue, or into one 
of a fibrous or cartilaginous appearance ; thus producing a nar- 
rowing, or even a complete obliteration of the passage. The 
same effect may be produced by the formation of abscesses in 
the substance of its parietes, or by the developement of tumours 
in its vicinity. Thus, a constantly increasing difficulty of de- 
glutition has sometimes arisen from the compression of the 
oesophagus by an aneurism of the aorta, by a mass of obstruct- 
ed lymphatic ganglions, or by an exostosis of the body of a ver- 
tebra. (Bleuland.) 

The parietes of the oesophagus sometimes become attenu- 
ated and softened. One of the consequences of this softening 
of the cesophagean parietes is their spontaneous perforation, 
which presents the same anatomical characters as that of the 
stomach. Some cases have been described of gangrene of the 
oesophagus; but many of them, if not all, seem to me to be 
merely cases of pultaceous softening of the part. 

Effusion into the thorax is the most common result of per- 
foration of the oesophagus. The perforation, in all the cases 
hitherto observed, has taken place in the thoracic portion of 
the passage, near the cardiac orifice ; and the surrounding part 
of the parietes has sometimes been found altered and softened, 
as already described, and sometimes, without any appreciable 
alteration. It has been observed at all ages. M. Veron has 
recorded a case of it in an infant just born. M. Guersent* ! 
has published the case of a girl, aged seven, that was carried 
off by an acute disease of which the predominant symptoms 



* Bulletins de la Faculte de Medicine, 1807, p. 73. 



172 DISEASES OP THE ALIMENTARY CANAL 

were vomitings at the commencement, and then diarrhoea, 
coma, and convulsions. The right side of the chest, which had 
lost its resonance, contained a brown fluid, in which floated 
flocculi of a deep green colour. There was discovered in the 
right pleura, a few lines above the diaphragm, an oval lacera- 
tion in the parietes of the oesophagus. Every where else the 
parietes of the oesophagus and stomach were sound. 

Another case of perforation of the oesophagus, in which there 
were also four perforations of the stomach, has been given us 
by M. Bouillaud.* The individual had been suffering for six 
weeks from pain in the stomach. When examined by M. 
Bouillaud, he presented all the symptoms of acute irritation of 
the alimentary canal. For the four succeeding days he had 
copious vomitings, and was then seized with a kind of apoplec- 
tic attack, and died in a state of coma. At the moment of 
making an incision into the thorax, a quantity of gas escaped 
from its left side ; and, on examination, the left lung appeared 
compressed, and two glasses of a brownish fluid were found in 
the cavity of the pleura. The pleura itself was injected, and 
presented several bright red patches. A little above the car- 
diac orifice, and towards the left side, was a small perforation, 
and, somewhat higher, a laceration about an inch and a half in 
length : the stomach had four perforations in the splenic region, 
the largest of which was about the size of a six-pence. The 
gastric mucous membrane was injected generally. 

In other cases, the perforation of the oesophagus is stopped 
up by the aorta, or trachea, so that no effusion takes place ; and 
in others, a double perforation occurs, and the oesophagus 
communicates with the interior of the aorta or trachea. 

The oesophagus presents the same lesions of secretion as the 
other portions of the alimentary canal. Pus and tuberculous 
matter have been found underneath its mucous membrane ; 
and on its free surface false membranes are occasionally form- 
ed. M. Gari, resident physician at the Hbpital des Enfans- 
Trouves, lately showed me the oesophagus of a new born in- 



* Archives de Medicine, vol. i. p. 531. 



ABOVE THE DIAPHRAGM. 173 

fant, the internal surface of which was lined, for about a third 
of its extent, with a layer of whitish, solid matter, which could 
not be detached without difficulty from the subjacent mem- 
. brane, and seemed to me to be situated beneath the epithe- 
lium. There was no trace of false membrane in the rest of the 
alimentary canal. 



CHAPTER II. 



Congenital Lesions of the Portion of the Alimentary Canal sit- 
uated above the Diaphragm. 



These we shall now consider successively as they exist in 
the mouth, pharynx, and oesophagus. 

The mouth may be either completely deficient, or only im- 
perfectly developed. The former kind of malformation is 
termed astomia, the latter, atelostomia. 

The different malformations comprehended under those two 
generic terms have this remarkable circumstance attending 
them, that they correspond more or less exactly to the natural 
state of the different parts of the mouth at various stages of 
their formation during fcetal life ; whence it follows that many 
of them are merely the result of an arrest of the developement 
of the parts affected. 

Astomia is the natural state of the foetus during about the 
first six weeks of its existence. It may, however, continue up 
to the period of birth ; and then, in place of mouth, cheeks, 
&c, we find merely a gaping orifice, situated, sometimes at 
the base of the cranium, sometimes where the nasal fossae 
should be, sometimes towards the middle of the cervical re- 
gion, and, lastly, where there is anencephalia, at the most ele- 



174 DISEASES OP THE ALIMENTARY CANAL 

vated point of the spinal column. Through this orifice there 
is access to the deeper seated parts of the alimentary canal. 

Atelostomia comprises a great number of malformations 
which I shall now briefly enumerate. 

The face may be completely absent, constituting aprosopia, 
or be but imperfectly developed, ateloprosopia. 

When aprosopia exists, the cranium may be well formed ; 
imperfect, especially with respect to the frontal bone ; or alto- 
gether deficient. 

Of ateloprosopia there are several degrees. Thus, in some 
cases, many of the various portions of bone, which when united 
form the superior maxillary bone, continue in their rudiment- 
ary state, or are altogether deficient. In others, the superior 
maxillary is perfect, but the inferior is absent {agnathia) or im- 
perfect (atelognathia). 

When there is agnathia, instead of the inferior maxillary 
bone we find nothing but a kind of tubercle formed of skin, 
cellular tissue, fat, and some few muscular fibres. In such 
cases, the masseter muscles have been found inserted into the 
palatine bones. The superior orifice of the alimentary canal 
is in these cases situated either immediately beneath the fleshy 
tubercle already described, or lower down in some point of the 
neck. 

The absence of the lower jaw may be the only malforma- 
tion of the face; and, on the other hand, there are cases in 
which the inferior maxillary is the only one of the bones of the 
face that is developed. 

Atelognathia presents the three following principal varieties : 
1. the inferior maxillary bone is of the usual size and form, but 
is composed of two pieces separated on the median line, as 
they naturally are before birth ; 2, it is composed of several 
pieces united by cartilage, which is the natural formation of 
the bone in birds ; 3. it continues very small, and merely exists 
in the rudimentary state, in which case the chin is remarkable 
for its little developement. 

The lips likewise present some malformations. One, or 
both, may be absent, which constitutes acheilia ; or they may 
be but imperfectly developed, which is termed atelocheilia. 



ABOVE THE DIAPHRAGM. 175 

The latter results either from the presence of a fissure extend- 
ing more or less towards the cheeks, where the commissure 
ought to be, or from the lips being too short to meet, or, lastly, 
from the division of one or both. 

On account of the resemblance of the lip in this last case to 
that of a hare, this malformation has been termed harelip. 

The division of the lower lip is very seldom found as a con- 
genital malformation ; however, Meckel and Shubarth have 
each recorded some instances of it. In the cases related by 
these authors, the division was in the centre of the lip, the up- 
per lip was also divided, and there w r ere several other malform- 
ations besides. It is much more frequently observed in the 
upper lip, where the longitudinal cleft that constitutes it is but 
very rarely situated on the median line : Nicati has mentioned 
a case in which it was so situated, and Lafaye, another, in 
which there were also two lateral clefts. The lip is generally 
divided perpendicularly at one or both sides of its middle por- 
tion, opposite to where the os incisivum is united to the os max- 
illare. When one side only is divided, the harelip is said to be 
simple, when both, double. When simple, it occurs most fre- 
quently at the left side. It may be the sole malformation ex- 
isting, or be accompanied by different degrees of division of 
the maxillary bone, or other malformations. The malforma- 
tion most frequently complicated with harelip is the non-union 
of the os incisivum with the os maxillare. We then find behind 
the upper lip a small osseous tubercle, distinct from the os max- 
illare, and containing all the incisor teeth, or only some of them. 
In this latter case, the incisors which are not contained in the 
tubercle, are found in another portion of the os incisivum ad- 
hering to the os maxillare ; for that bone (os incisivum) is orig- 
inally formed in as many distinct parts as there are teeth to be 
contained in it ; consequently, there are at first four ossa incis- 
iva, two at each side ; and it sometimes happens that they con- 
tinue separate from each other, or from the maxillary bones, in 
which case it is observed that the lip continues also divided into 
as many portions as there are bones that do not unite. This 
persistence of the division of the os incisivum is the natural 



176 



DISEASES OF THE ALIMENTARY CANAL 



state of the part in a great many animals, and in them the lip is 
also developed in several distinct portions, the separations be- 
tween which correspond to those between the small ossa in- 
cisiva. 

Thus, then, the division of the upper lip into several portions 
appears to be the natural state of the part at a certain period of 
foetal life ; and harelip, to be merely the continuance of this 
state. But there is also a period in the developement of the 
foetus, when the osseous partition that separates the mouth 
from the nasal fossae, is very incomplete ; and the velum palati, 
which is the continuation of this partition, is formed in several 
distinct parts, that do not unite until an advanced period of the 
evolution of the foetus. This particular state, which, in the 
human subject, is natural only in the foetus, is permanent in a 
great many animals : and if we examine successively the mam- 
malia, birds, fishes, and reptiles, we shall find the separation 
between the cavities of the nose and mouth becoming less and 
less marked, and at last disappearing altogether; we shall also 
find the soft palate becoming divided, or disappearing either 
wholly or partially. These different conformations, which are 
thus temporary in the human foetus, and permanent in many 
animals, may continue to exist in man also after birth, and are 
then to be regarded as malformations. The most remarkable 
are, 1. a simple want of union between one of the palatine 
processes of the maxillary bone and the os incisivum of the 
same side; 2. a similar separation at both sides; 3. the non- 
union of the palatine processes themselves ; 4. the complete ab- 
sence of one or both palatine processes; 5. the complete ab- 
sence of the os incisivum, and at the same time, of the middle 
part of the upper lip ; 6. and lastly, the simultaneous absence 
of the os incisivum and of the two palatine processes. 

In the soft palate we may observe, 1. a non-union of the two 
lateral parts of which it is originally formed; 2. those two parts 
united, but the uvula divided ; 3. the uvula in a rudimentary 
state, or else completely absent, a malformation chiefly con- 
nected with the want of developement of the circumflexus 
palati muscle. 



ABOVE THE DIAPHRAGM. 177 

The various congenital divisions of the lips, and hard and 
soft palate, that have been just enumerated, sometimes occur 
together. 

The tongue also is subject to various malformations. How- 
ever, as it is formed at an earlier period than the other parts 
of the mouth, being visible from the seventh week, it must less 
frequently depart from its natural mode of conformation. 

The tongue may be altogether wanting, which constitutes 
the malformation termed aglossia; this however hardly ever 
occurs except in those cases where there is at the same time 
acephalia or aprosopia. We must not confound the true aglos- 
sia with that which is only apparent, and arises from the ab- 
sence of the internal muscles of the tongue ; constituting one 
of the kinds of defective developement of that organ, compre- 
hended under the term ateloglossia. 

The following are the principal varieties of ateloglossia. 

1. Absence of some of the component parts of the tongue, as 
of the muscles on one side, of the lenticular papillae, or of the 
mucous membrane. 

2. Smallness of the tongue, or microglossia. In many cases 
of this description, the smallness of the tongue depends on the 
circumstance of one of the two parts of which it is naturally 
composed not having been developed. One of these parts 
consists of the muscles inserted into the os hyoides, and may 
be termed its hyoidean or posterior portion ; the other or an- 
terior part is composed of muscles terminating in fibrous laminae 
situated in various parts of the organ. In the three classes of 
vertebrated animals provided with lungs, both these portions 
are to be found, but not equally developed, the anterior pre- 
dominating in the mammalia, and the posterior, in birds and 
reptiles. In fishes, the hyoidean portion only is to be found. 
Now, if we apply these facts to the developement of the tongue 
in man, we shall find reason to think that its posterior portion 
is formed first; that, consequently, it must be much less fre- 
quently deficient than the anterior; and therefore, that, in most 
cases of microglossia, the extreme smallness of the tongue is 
owing to the absence of the anterior portion. Observation con- 
firms the justness of these theoretic views, for, in all case* of 

Vol. II. 24 



178 DISEASES OF THE ALIMENTARY CANAL 

microglossia hitherto examined, it has been ascertained that 
the tongue was reduced to its hyoidean portion. It then ap- 
pears at the bottom of the mouth like a small nipple furnished 
with a few muscular fasciculi that are inserted into the os 
hyoides and lower jaw. In some cases the mucous membrane 
is only sufficiently developed to cover the stump just described; 
sometimes, however, it is prolonged beyond the stump, and ad- 
vances towards the lips; but still its folds contain only cellular 
tissues between them: an arrangement similar to this is observ- 
ed in some kinds of fish. In many cases of this malformation, 
the persons affected were not deprived of speech; their pro- 
nunciation, however, was not very intelligible ; and, in order to 
articulate, they were obliged to approximate the chin to the 
larynx. They had also the sense of taste, but were unable to 
chew their food, or swallow without the assistance of their 
fingers. 

3. Macroglossia is the opposite kind of malformation to the 
preceding; the tongue being larger than natural. We learn 
from embryology that the tongue has at an early period of fetal 
life a much more considerable relative developement than it 
has subsequently. Now, it is probable that macroglossia re- 
results from the nutrition of the tongue continuing for a longer 
time than usual to proceed as at the earliest period of the evo- 
lution of the embryo; in which case we should have an exam- 
ple of the excessive bulk of an organ depending on a real ar- 
rest of developement. The same thing may also be observed 
in the. left lobe of the liver, which, being naturally larger than 
the right in the fetus, sometimes continues so in the adult. The 
same, again, takes place, when we observe in the adult an un- 
usual developement of the thymus, supra-renal capsules, and 
certain vessels, which, in the natural order of things should 
diminish in size after birth. 

Of macroglossia there are two degrees. In the first, the 
tongue, though unusually large, is yet not sufficiently so to ex- 
ceed the limits of the mouth: this, together with thick lips, is 
one of the characteristics of a scrofulous constitution. In the 
second, it is so large as to hang out of the month. 



ABOVE THE DIAPHRAGM. 179 

4. The tongue has sometimes been found bifurcated at its 
anterior extremity; a conformation which, as is well known, 
belongs naturally to many reptiles, such as the snake, and some 
of the lizard tribe. I am not aware that it has been ascertain- 
ed to belong to man at any period of his foetal existence. In 
most of the cases in which this malformation has been observed 
in the human subject, it was accompanied by others, such as 
harelip, cyclopia, and preternatural elongation of the uvu!a. 

5. Examples have been seen of two tongues, situated one 
over the other. They were separate anteriorly, but united at 
their bases. 

6. There have been also instances of congenital adhesion of 
the tongue, either to the lower lip, or by its tip to the floor of 
the mouth. 

The two orifices of the mouth are likewise liable to some 
malformations. Those of the posterior orifice have already 
been described as irregular conformations of the soft palate. 
The principal malformation the anterior orifice presents is its 
occlusion, which may either result from the simple adhesion 
of the lips, or from their being united by a membrane. The 
absence of the anterior orifice of the mouth is the natural state 
of the parts at an early period of fcetal life : so that its continu- 
ance is the result of an arrest of developement resembling that 
which causes the persistence of the membrana pupillaris, or 
that which keeps the eyelids closed after birth. When there is 
no aperture between the lips, it sometimes happens that the 
mouth communicates externally by an opening in some part of 
the cheeks; in other cases, the mouth has no communication 
with the exterior, and the superior orifice of the alimentary 
canal is situated at a greater or less distance from the mouth, 
as in the neck, for instance. 

As the malformations of the teeth are comparatively unim- 
portant in a pathological point of view, I do not think it neces- 
sary to dwell upon them here. Whoever wishes for detailed 
information on the subject may consult the excellent work of 
M. Serres, Sur le Developpement des Dents, which he will find 
fully satisfactory. 



180 DISEASES OF THE ALIMENTARY CANAL 

The musculo-membranous duct through which the food is 
conveyed from the mouth to the stomach presents but very few 
malformations. 

We have some cases of complete absence of the pharynx; 
but it is a very rare occurrence, and has hitherto been observ- 
ed only in acephalous monsters. The pharynx has been found 
to terminate in a cul-de-sac at each of its extremities. It has 
also been found double in foetuses with two heads and two 
necks springing from a single body. Lastly, it has been ob- 
served to present a partial dilatation, or kind of pouch more or 
less analogous to that of some species of birds: this pouch was 
in some cases constituted by all the tunics of the pharynx, and 
in others solely by the mucous membrane, which was distended, 
and formed a hernia through the muscular tunic. 

The malformations of the oesophagus are somewhat more 
various than those of the pharynx. The study of its imperfec- 
tions of developement may serve to throw some light upon its 
natural mode of developement, which is as yet but imperfectly 
understood. In some cases, only its superior extremity is found 
terminating in a cul-de-sac, between which . and the stomach 
there is merely cellular tissue. In others, we find a duct pro- 
ceeding upwards from the cardiac orifice of the stomach to the 
extent of a few inches, and then ending in a cul-de-sac, with 
nothing but cellular tissue beyond it, as in the preceding case. 
Sometimes it forms a solid cord throughout; at other times, its 
cavity does not become obliterated until it arrives within a 
short distance of its insertion into the stomach. In a case of 
this description, published by Van Cuych, the infant vomited 
every thing that it attempted to swallow, and died three days 
after its birth. Sir Astley Cooper has recorded another case 
in which the oesophagus was totally deficient; the pharynx 
terminated in a cul-de-sac, and the stomach had no cardiac ori- 
fice: the child lived eight days. These various malformations 
resemble those not unfrequently observed in the rectum. A 
still more extraordinary case is that published by M. Martin in 
the Observdteur des Sciences Medicates (Marseilles, July, 1825). 
In a child that died thirty-six hours after birth, there was no 
trace of the pharyngeal extremity of the oesophagus to be found 



ABOVE THE DIAPHRAGM. 181 

but a canal of a few inches in length, and terminating in a cul- 
de-sac. Just above the region of the bronchia, the trachea pre- 
sented an orifice, through which a probe was passed into a 
membranous, elastic duct, of the diameter of a small quill, that 
led to the stomach, and thus established a communication be- 
tween the cavity of that organ and the air passages. In like 
manner, in many cases of absence of the rectum, we find the 
colon opening into the bladder or some other organ. 

The oesophagus, instead of being absent or imperfectly de- 
veloped, may have a tendency to exceed its natural propor- 
tions. In the first place, this happens in foetuses that are more 
or less completely double in their various parts : in those in 
which two necks spring from a single thorax, the oesophagus is 
single below, and double above ; in those that have a single 
neck, and a double thorax, the reverse is the case. This ten- 
dency of the oesophagus to duplication has also been observed 
in cases where no other malformation was to be found. Thus, 
in Meckel's plates of pathological anatomy, we find the repre- 
sentation of an oesophagus bifurcating opposite the firt rib : the 
branches go off in a semicircular form, and continue distinct till 
they arrive opposite the sixth rib, when they approximate, unite 
closely, and at last the oesophagus becomes single again, and 
continues so for the rest of its course. In other cases the 
oesophagus becomes dilated below, so as to resemble the crop 
in birds. 

In some cases of general transposition of the viscera, the 
oesophagus has been found lying on the right side of the body 
of the vertebrae. 



182 



DISEASES OF THE HEART. 



CIRCULATORY APPARATUS. 



SECTION I. 



DISEASES OF THE HEART. 



In this class of diseases we shall find the same lesions as in 
the other organs whose pathology we have already been inves- 
tigating; namely, lesions of circulation, nutrition, secretion, and 
innervation: but, in diseases of the circulating system, the im- 
portance which attaches to these lesions is altogether different 
from that which they assume in other organs. Thus, in dis- 
eases of the heart, hypercemia plays a very secondary part 
when compared with the important character it assumes in 
diseases of the lungs and alimentary canal. The lesions of 
nutrition and secretion are likewise comparatively unimportant, 
unless when they proceed so far as to produce an alteration in 
the dimentions of the heart, or a disproportion either in the 
thickness of its parietes or in the capacity of its cavities, and 
thereby create an obstacle to the entrane or exit of the blood. 



DISEASES OF THE HEART. . 183 



CHAPTER I. 



LESIONS OF CIRCULATION. 



The alterations dependant on the quantity of blood which 
the heart is capable of receiving in its parenchymatous struc- 
ture, constitute a very small portion of the diseases of that 
organ. Of the symptoms which during life announce hyper- 
asmia of the heart, we know very litttle indeed; and as to the 
post mortem traces of this affection, we must in candour con- 
fess, that in many cases it is difficult to decide whether the 
various shades of red observable in the substance of the heart 
or on its internal surface, should be regarded as the marks of 
a hyperajmia formed during life, or as an alteration produced 
after death and altogether dependant on physical causes. 

In fact, the heart is one of the organs which evince the great- 
est aptitude to these post mortem colorations. If we open an 
animal shortly after it is killed, and examine the heart, we find 
its internal surface pale, and its substance but faintly coloured; 
but if the same heart be exposed to the air and sun for a few 
hours, its internal surface changes to a bright scarlet, and its 
muscular structure assumes a deep red colour. When the ex- 
amination of the body is deferred, in hot or damp weather, 
until thirty hours after death, the heart is invariably found red: 
in some cases the redness is confined to its internal surface, 
which then appears as if dyed by some red colouring matter, 
either uniformly, or in isolated patches; in other instances, the 
red colour extends through its parietes, to which it imparts a 
dark livid hue, which is occasionally accompanied by the ap- 
pearance of ecchymoses on its external surface. 

This post mortem colouring of the heart is not always found 
to the same extent even in those bodies that are opened under 
similar circumstances. Cmteris paribus, it is most marked in 
those individuals who at the time of their death have a large 



184 



DISEASES OF THE HEART. 



supply of blood in the system; some bodies too have a much 
greater tendency to putrefaction than others, and in them the 
red colour of the heart is always exceedingly marked. 

These few observations may serve to render the morbid 
anatomist cautions how he attributes all red appearances in the 
heart to inflammation of that organ, as the greater proportion 
of them should with more propriety be referred to post mortem 
alterations. No doubt, however, can exist that these appear- 
ances are occasionally produced during life, and are connected 
with a true state of active hyperemia; as in the following in- 
stances. During the Summer of 1824, a fatal distemper raged 
amongst the horses in Paris, at which period I made a great 
number of dissections immediately after the animals were 
slaughtered, and generally found the heart of a deep red colour. 
The redness was in some cases conlinedto the internal surface 
of the heart, where it appeared in detached red points, or else 
uniformly diffused. In other cases the redness extended to 
the fleshy substance of the heart, which in those cases was re- 
markably friable, and easily detached from its internal mem- 
brane, underneath which I found in three instances several 
small deposits of puriform matter. These alterations occurred 
more frequently in the left than in the right side of the heart. 
In some cases, they were confined to the aortic valves, which 
were at the same time swoln and easily broken down into a 
pulpy mass. 

One of the lesions most constantly found in animals poison- 
ed by the deuto-chloride of mercury, is a number of red patches 
spread over the internal surface of the heart. In this as in the 
preceding case, no doubt can be entertained that these colour- 
ed spots are produced by an active hyperaemia formed during 
life ; and it is reasonable to conclude that this poison, when 
administered in sufficient quantity to produce death, acts on 
the heart, and produces there an irritation similar to that which, 
in a weaker dose, it excites in the mucous membrane of the 
mouth. 

But it is not in animals only, that the formation of these dif- 
ferent degrees of red colour in the heart can be traced to a 
period prior to death ; in the human subject likewise, it may 



DISEASES OP THE HEART. 185 

in some cases be traced to the same period : as in the follow- 
ing examples. 

1. I examined at La Charity the body of a man who had 
presented many of the symptoms usually attendant on pericar- 
ditis, viz. a sudden attack of dyspnoea, dull pain in the precor- 
dia, tumultuous palpitations, frequent and irregular pulse, suf- 
focation and death. On dissection no morbid appearance what- 
ever could be detected in the pericardium, or in the substance 
of the heart ; neither could any trace of disease be discovered 
in the auriculo- ventricular orifices, or in the blood-vessels. The 
only appreciable lesion was a bright red colour on the internal 
surface of the left auricle and ventricle. 

2. Another individual who had habitually enjoyed excel- 
lent health, was suddenly seized with pain in the cardiac 
region, dyspnoea, and palpitations such as usually attend on 
hypertrophy of the heart ; each contraction of the ventricles 
was followed by a dull " bruit de rajie." Three weeks after 
the accession of these symptoms, he was attacked with pleu- 
risy, of which he died. On dissection, the only morbid appear- 
ance discoverable in the heart, was a bright red colour of the 
aortic valves, which were evidently in a state of tumefaction, 
and contained in their structure two white points formed by a 
semifluid and apparently steatomatous matter. 

3. It not unfrequently happens, that persons labouring under 
organic affections of the heart are suddenly seized with a vio- 
lent aggravation of all their former symptoms, and, when death 
ensues, a bright red colour is discovered in the heart, which 
cannot be accounted for, either by the putrefactive process, or 
any other physical cause acting after death. In some cases, 
this redness is uniformly diffused, in others it is confined to one 
side of the heart, whilst in a third set of cases it is still more 
circumscribed, and exists only in the valves. In all such cases, 
is it not an acute hypersemia supervening on the old affection 
of the heart, which produces the aggravated symptoms and fa- 
tal termination of the disease ?* 



* See some arguments in support of this opinion in my Clinique Medicate. 

Vol. II. 25 



186 DISEASES OF THE HEART. 

Ancsmia of the heart has not as yet been made an object of 
special investigation : all that we can at present say on the 
subject is, that it generally accompanies atrophy of that organ, 
and, like it, not unfrequently succeeds to a state of hypertrophy 
and congestion. It may, however, exist independently of the 
atrophy of its tissue, as is observed in certain chronic diseases, 
and in some cases of dropsy, where the tissue of the heart is 
found remarkably pale and exsangueous. 

This state of the heart is characterized by a remarkable dis- 
coloration of its tissue, and cannot be better described than 
by comparing it to the appearance which that viscus presents 
after a long maceration in water. 



CHAPTER II. 



LESIONS OF NUTRITION. 



These lesions may be divided into two classes, the first com- 
prehending those which create an obstacle to the free entrance 
of the blood into the heart, or to its expulsion from it ; the sec- 
ond, those that do not present any obstacles to the circulation 
of the blood through the heart. 



DISEASES OF THE HEART. 187 



ARTICLE I. 



LESIONS OF NUTRITION THAT IMPEDE THE FREE CIRCULATION 
OF THE BLOOD THROUGH THE HEART. 



It has been laid down by Laennec, that the size of the heart 
is natural when it nearly equals that of the fist of the individual ; 
whence it follows that the size of the heart is different in differ- 
ent individuals, and that its healthy condition depends more on 
its relative, than on its absolute dimensions. The parietes of 
the left ventricle are naturally twice as thick as those of the 
right ; in the latter, however, the columnae carneae are larger, 
but the net work on its internal surface is much coarser and its 
meshes less numerous. When both ventricles are cut across, 
the parietes of the right ought to collapse so as to obliterate its 
cavity, but those of the left ought not. The capacity of both 
ventricles is in the physiological state equal. 

The relative proportions assigned to the ventricles in the pre- 
ceding paragraph, do not apply to infancy or old age : at both 
these extremes, the thickness of the parietes of the left ven- 
tricle is to that of the right as three or four to one. But, 
though the proportional thickness of the left ventricle is nearly 
equal at both these ages, nothing can be more different than 
the pulse. The force or hardness of the arterial pulsations do 
not, then, it is evident, depend exclusively on the thickness of 
the walls of the left ventricle. 

The nutrition of the heart may be so modified as to produce 
various alterations in the dimensions of its cavities, or in the 
thickness of its parietes: we shall now proceed to consider 
these alterations. 

Increased thickness of the heart's parietes is generally desig- 
nated by the term hypertrophy; indeed the term was originally 



188 DISEASES OF THE HEART. 

restricted to this class of affections, although its present appli- 
cation is much more extensive. 

Hypertrophy of the heart may be general, that is, may affect 
the parietes of its four cavities ; or it may be partial, in which 
case the left ventricle is most commonly affected. The hyper- 
trophy of this ventricle presents several varieties. It may be 
exclusively confined to the columnse carnese, which then equal 
or even exceed the natural size of those of the right ventricle. 
Sometimes the hypertrophy is limited to the pillars of the 
mitral valve ; in other cases the septum is more especially 
affected; whilst in others the increase of thickness ex- 
tends over the whole of the parietes of the ventricle. In this 
last case, the thickening may be at its maximum at the base of 
the heart, and diminish gradually towards its apex, which some- 
times retains its natural thinness when all the rest of the parie- 
tes are three or even four times as thick as natural. In other 
individuals, again, the thickening is equal and uniform from the 
base to the apex, which then loses its pointed form, and acquires 
a rounded shape. Lastly, it sometimes happens that the hy- 
pertrophy is greatest about midway between the apex and base 
of the heart, or is even exclusively confined to that part. When 
the septum is principally affected, the capacity of the right 
ventricle is so diminished, that it sometimes looks like a small 
appendix attached to the left ventricle. 

The parietes of the right ventricle are seldom so much hy- 
pertrophied as to present an evident thickening to the eye ; 
Laennec, however, has seen them acquire the thickness of five 
lines, and MM. Bertin and Bouillaud, of fifteen : the existence 
of this affection in a minor degree may be detected by the pa- 
rietes not collapsing when cut across, and by the preternatural 
developement of the columnse carnea?. 

When one ventricle is in a state of hypertrophy, the other 
may be so likewise, may retain its natural dimensions, or may 
be reduced to a state of atrophy. 

Hypertrophy of the auricles is very rare, and, when it does 
exist is almost always accompanied by hypertrophy of the ven- 
tricles. 



DISEASES OP THE HEART. 189 

The parietes of the heart when affected with hypertrophy, 
may retain their natural consistence, which is by far the com- 
monest case; or may be more or less indurated, which is rare; 
or may present different degrees of softening, which is still 
more uncommon. 

Hypertrophy of the parietes of the heart may accompany 
different conditions of its cavities ; thus : — 1. The cavities may 
retain their natural dimensions. 2. They may be dilated. In 
this case the whole volume of the heart is augmented. It con- 
stitutes the active aneurism of Corvisart, and the eccentric hy- 
pertrophy of MM. Bertinand Bouillaud. 3. The hypertrophy 
may be attended with diminution of the cavities. (Concentric 
hypertrophy of MM. Bertin and Bouillaud.) In this form of the 
disease, the heart sometimes retains its natural size, in other 
cases its volume is increased, and in others, diminished. Each 
of these varieties is characterized by a peculiar train of symp- 
toms. 

We have hitherto considered hypertrophy only as affecting 
the muscular tissue of the heart ; but there are other tissues in 
this organ which are liable to have their nutrition preternatu- 
rally increased, or, in o'ther words, are subject to hypertrophy. 
There are, for instance, certain parts of the heart where the 
fibrous tissue naturally exists, in such a rudimentary state, how- 
ever, that it requires a very minute dissection to demonstrate 
its existence ; notwithstanding which, it sometimes acquires 
such a degree of developement, as to form considerable tu- 
mours, and present a mechanical obstacle to the heart's action. 
These alterations are most observable in the margins of the 
several orifices of the heart, and in the valves, the thickening 
and irregular form of which frequently depend on the hyper- 
trophy of the fibrous tissue which enters in a rudimentary state 
into their composition. It frequently happens, that this fibrous 
tissue, at a certain stage of its hypertrophy, changes its nature 
altogether, loses its fibrous appearance, and is reduced to a ho- 
mogenous mass resembling cartilage. 

Atrophy of ihe walls of the heart is less common than their 
hypertrophy. It may exist without any other alteration of the 
heart, or it may coincide with an increase in its volume, in 



190 



DISEASES OF THE HEART. 



which case the cavities are dilated, or lastly, it may be accom- 
panied by a notable diminution in the size of the organ. 

Atrophy of the heart sometimes proceeds so far that its 
parietes are reduced to mere membranes in which scarcely a 
trace of muscular fibre is distinguishable. In such cases, the 
fat which naturally exists around the heart is generally much 
increased, and its secretion becomes more active in proportion 
as the muscular fibres disappear. 

In general, atrophy of the heart comes on without any as- 
signable cause. As anaemia of this organ may succeed to its 
hyperemia, so its atrophy may succeed to a preceding hyper- 
trophy. Laennec records the case of a woman fifty years old, 
who for twelve months had constantly presented all the symp- 
toms of organic disease of the heart, from which she was sub- 
sequently relieved by Valsalva's method of treatment. Two 
years after her recovery, she was seized with cholera morbus, 
and died. On dissection, her heart was found remarkably 
small, scarcely exceeding in size the heart of a child of twelve 
years of age. Its external surface bore an exact resemblance 
to a wrinkled apple, the wrinkles being generally directed from 
the apex towards the base. 

Atrophy of the heart is likewise met with in those cases 
where any morbid production, either solid or fluid, is developed 
on its surface, or in its substance. MM. Bertin and Bouillaud 
found the heart remarkably small in an individual affected with 
hydrops pericardii. In a case of chronic pericarditis, where 
the heart was enveloped in a thick layer of false membranes, I 
found only a delicate layer of muscular fibres interposed be- 
tween them and the internal membrane. I likewise observed 
the same appearances in a child of three years of age, whose 
heart was incrusted with a layer of tubercular matter. In 
these several cases, the atrophy may be considered as the result 
either of a sort of balance established in' the nutritive process, 
or of the compression exercised on the heart by the morbid 
productions which surrounded it. 

In several diseases in which persons die much emaciated, 
the heart is found on dissection to have participated in the gen- 
eral atrophy of the muscular system : this, however, is not 



DISEASES OF THE HEART. 191 

uniformly the case ; for, in many phthisical patients who die in 
an extreme state of marasmus, the heart retains its natural vol- 
ume, or, if its size appears diminished, its diminution is ap- 
parent, and depends on the circumstance of the parietes collaps- 
ing, in consequence of their containing little or no blood. 

There are some cases on record of the walls of the heart 
being thinner than natural in some points, at the same time that 
they were preternaturally thicker in others. 

The capacity of the heart's cavities may be either increased 
or diminished. The increase of their capacity may co-exist 
with, 1. a natural condition of the parietes; 2. an increase of 
their thickness ; or, 3. a diminution of their thickness. The 
second case constitutes the active aneurism of Corvisart ; it 
occurs more frequently in the left than in the right side of the 
heart ; the third, which is more common in the right side, con- 
stitutes the passive aneurism of the same author. 

The dilatation may affect an entire cavity, or may be con- 
fined to a single point, where it produces a sort of pouch com- 
municating with the interior of the Cavity to which it is ap- 
pended. The size of these pouches varies from that of an al- 
mond, to that of a large hen egg. In their interior, they gen- 
erally contain fibrous concretions, formed of successive layers, 
such as are found in arterial aneurisms, to which indeed the 
partial dilatations of the heart bear in many respects a striking 
analogy. The parietes of the cavities from which they grow 
are in some cases thickened, and in others reduced to a re- 
markable state of atrophy. 

M. Breschet, in an excellent essay in which he has brought 
together all the cases of this description that have been hitherto 
published, has described this morbid appearance under the 
title of false consecutive aneurism of the heart. But this de- 
nomination, which implies that the aneurism has been formed 
by the rupture of the internal membrane of the heart, is not, as 
I conceive, applicable to every case of this affection ; for in 
some there is no evidence whatever of any such rupture having 
taken place ; indeed the contrary was clearly established in a 
case I examined with my friend M. Reynaud, shortly after the 
publication of M. Breschet's paper, in which we found that the 



192 DISEASES OF THE HEART. 

lining membrane of the left ventricle was dilated in two places, 
so as to form two pouches, but had evidently undergone no 
solution of continuity in either, the parietes of the pouches being 
in fact formed as in the true primitive arterial aneurism, by the 
dilatation of all the coats. On examining the left ventricle, in 
this case, we found its internal membrane considerably thicken- 
ed, and in many points of a dull white colour ; the subjacent 
cellular tissue was likewise preternaturally developed, and 
might be divided into several distinct layers. About the mid- 
dle of the posterior surface of the left ventricle, where the al- 
teration of the internal membrane was most apparent, there 
existed a round opening about one fourth of an inch in diam- 
eter, which led into a spherical pouch as large as a walnut. 
The parietes of this pouch were separated from the pericardium 
only by a delicate expansion of muscular fibres, and were 
formed by a thick layer of dense fibrous tissue, which by dis- 
section was easily divided into two layers, one superficial, more 
delicate than the other, and of an opaque white colour ; the 
other thicker, resembling the middle coat of arteries when al- 
tered by disease, and containing in its substance several fibro- 
cartilaginous and osseous points. This latter membrane was 
uninterruptedly continuous with the internal membrane of the 
ventricle. Another pouch of the same description, but of 
smaller dimensions, was attached to the anterior surface of the 
same ventricle. They each contained coagula of fibrine.* 

Diminution of the capacity of the heart's cavitives may be 
either apparent or real. It is only apparent in those cases of 
general anaemia where the heart, in consequence of containing 
little or no blood, is enabled to contract on itself. When the 
diminution of capacity is real, it may co-exist, 1. with a natural 
condition of the parietes; 2. with their hypertrophy; or, 3. 
with their atrophy. We have already seen that the capacity 
of the right ventricle may be materially diminished by the sim- 



* For further particulars of this interesting case, see the detailed account by 
M. Reynaud, in the 2nd vol. of the " Journal Hebdomadaire de Mtdecine." 



DISEASES OF THE HEART. 193 

pie thickening of the interventricular septum ; the same effect 
may likewise be produced by the hypertrophy of its columnae 
carneae. Diminution in the capacity of the right ventricle un- 
accompanied by any other alteration of the heart, is frequently 
found co-existing with a state of general dropsy. 

The alterations in the dimensions and proportions of the 
heart above enumerated may be produced by various causes. 



FIRST ORDER OF CAUSES. 



Mechanical Obstacles to Hie Circulation. 



These obstacles may reside either in the orifices of the heart, 
in the arteries, or in the capillaries. 

A. Obstacles seated in the Orifices of the Heart. 

The orifices of the heart are occasionally so narrowed, either 
by congenital malformation, or by disease, as to prevent the 
free passage of the blood. Instead of this simple narrowing of 
the apertures, the obstacle to the circulation may be produced 
by various organic lesions 1 of the valves which surround them. 
These lesions shall presently be described. 

The alteration in the dimensions of the heart is generally 
found in that cavity which discharges its contents through the 
affected orifice. This rule is not, however, without its excep- 
tion: for it not unfrequently happens that the cavities at the 
right side of the heart are altered, when it is at the left side that 
the affection of the orifices exists. This apparent anomaly is 
easily accounted for, when we recollect the route which the 
blood takes in passing from the right to the left side of the 
heart. 

The orifices of the heart may continue for a long time in a 
state of disease, without producing habitually any appreciable 
Vol. II. 26 



194 DISEASES OF THE HEART. 

derangement of its action. But, in such cases, any effort, or 
violent exercise, any mental exertion, or excess of any kind, in 
short, any thing tending to accelerate the circulation, seldom 
fails to produce palpitations and dyspnoea. 



B. Obstacles in the Arteries. 



The aorta sometimes presents from its origin, or from its 
arch, to its bifurcation, a considerable diminution of its natural 
caliber; a malformation which has been repeatedly found co- 
existing with hypertrophy of the heart's parietes, or dilatation 
of its cavities. An evident diminution in the caliber of the pul- 
monary artery has likewise been observed to co-exist with the 
same alterations in the right side of the heart. It is reasonable, 
then, to conclude that a considerable degree of contraction of 
the great vessels into which the heart discharges its contents, 
must impede its free evacuation, in the same manner as those 
obstacles which are situated in the orifices of the auricles or 
ventricles. 

On the other hand, the aorta is sometimes found considera- 
bly enlarged in individuals affected with hypertrophy of the 
heart, or dilatation of its cavities. Are we to regard these mor- 
bid appearances as cause and effect, or as simple coincidences? 

Finally, there is a third class of cases in which the aorta is 
neither dilated nor contracted, but its coats are incrusted with 
numerous ossifications. Perhaps this incrusting of the parietes, 
by destroying their elasticity, deranges the circulation in the 
aorta, and consequently in the heart also. 



C. Obstacles in the Capillaries. 



We are altogether ignorant of how far obstacles seated in the 
general capillary system are capable of affecting the circulation 
in the heart. But, there are few points in pathology better 



DISEASES OF THE HEART. » 195 

established than that any impediment to the capillary circula- 
tion of the lungs is capable of producing hypertrophy and dila- 
tation of the heart. In fact, the lung in which the circulation 
of the blood is impeded, or otherwise retarded, is to the right 
side of the heart, what the liver, when gorged or obstructed, is 
to the vena porta?. I feel quite convinced, from the numerous 
researches I have myself made on this subject, that the conges- 
tion of the bronchial membrane in chronic catarrhs is a fre- 
quent cause of the diseases of the heart with which they are so 
constantly complicated. In such cases, the difficulty of breath- 
ing is often long antecedent to any local symptom of organic 
disease of the heart. And if, in phthisical persons, disease of 
the heart is comparatively a rare affection, although their pul- 
monary circulation is often so materially impeded, a sufficient 
explanation is afforded by the circumstance of the rapid dimi- 
nution which takes place in the mass of their circulating fluid. 
Neither do we observe in them those long, distressing par- 
oxysms of coughing, which occur in chronic catarrhs, and 
which by their repetition necessarily derange and impede the 
circulation in the pulmonary artery, and consequently in the 
heart itself. 



SECOND ORDER OF CAUSES. 



Active Hypercemia of the Membranes that invest the external 
and internal Surfaces of the Heart. 



In another work (the Clinique Medicale) I have endeavour- 
ed to prove that a certain proportion of hypertrophies of the 
heart originate in an acute or chronic attack of pericarditis. I 
have there related the cases of several individuals, who, with- 
out having previously presented any symptom of organic dis- 
ease of the heart, were suddenly seized with all the symptoms 
of pericarditis, from which they recovered, but still suffered 
from palpitations and hurried respiration. These, and other 



106 DISEASES OF THE HEART. 

symptoms of organic disease of the heart gradually increased; 
and when at last they terminated fatally, there was found on 
dissection, besides the organic disease, cellular adhesions or 
other morbid appearances in the pericardium, which attested 
the existence of an antecedent pericarditis. 

We have already discussed the question, how far acute or 
chronic hyperasemia of the internal membrane of the heart is 
capable of producing aneurism of that organ. But even though 
the facts adduced in support of that opinion may not be con- 
clusive, would not analogy lead us to admit it 1 For, wherever 
a muscular membrane contributes to form the parietes of a 
cavity, we constantly see hypertrophy of that membrane pro- 
duced by an antecedent hyperasemia of the mucous or other 
membrane which lines the interior of the cavity. 



THIRD ORDER OF CAUSES. 



Modification of the Innervation. 



An attentive observation of the commencement of certain 
organic diseases of the heart enables us to detect the existence 
of disease at a period prior to the formation of any organic al- 
teration of that organ ; and the symptoms which we then ob- 
serve appear in many cases to depend solely on some derange- 
ment in the heart's action, independently of any alteration in 
its texture. In such cases the heart, which beats too violently 
or too rapidly, is not more necessarily altered in its organiza- 
tion than any other muscle whose contractions are accomplish- 
ed irregularly and independently of the will. Now, the ner- 
vous system is the agent of these irregular movements ; it is 
therefore consistent with the soundest physiology to admit in 
the case of the heart, as well as in that of the muscles of ani- 
mal life, that a modification of the nervous influence may cause 
a modification of its contractions. But, we know that the mus- 
cle whose contractions are, for any length of time, rendered 



DISEASES OF THE HEART. 197 

more frequent or more violent by the influence of the nervous 
system, in the end becomes hypertrophied ; and why should 
not the same cause produce the same effect in the heart ? The 
term nervous palpitation is not, then, as has been said, a phrase 
by which we endeavour to conceal our ignorance, but the ex- 
pression of a positive fact. To conclude, the accurate re- 
searches recently made on the subject of the morbid anatomy 
of the heart have clearly proved, that we may find every pos- 
sible variety of hypertrophy of its parietes, or of dilatation of 
its cavities, unaccompanied by the slightest evidence of any 
antecedent irritation either of its external or internal surface, 
or the appearance of any obstacle whatever, either in the ori- 
fices of the auricles or ventricles, or in the rest of the circula- 
tory apparatus. 



ARTICLE II. 



LESIONS OF NUTRITION THAT DO NOT ALTER THE DIMENSIONS OF 
THE HEART. 



Among the lesions of this class, there are some which are 
generally connected with the lesions described in the preced- 
ing article, and have but few symptoms peculiar to themselves ; 
others, again, are made known to us by certain local or gene- 
ral symptoms ; whilst a third set exist without in any wise de- 
ranging the action of the heart, and are consequently interest- 
ing only to the anatomist. 



198 DISEASES OF THE HEART. 



§ I. Induration. 



We should distinguish carefully between induration and hy- 
pertrophy, for, though generally combined, they are in reality 
different affections, and may exist each independently of the 
other. When the heart is in a state of induration, it is particu- 
larly firm, and difficult to cut ; when struck with the scalpel, it 
sounds, as Laennec says, like a leather dice box. Corvisart 
states that he has sometimes heard a peculiar crackling sound 
on cutting into an indurated heart ; but Laennec was never 
able to detect this sound, nor have I myself remarked it. 

It sometimes happens, that the heart is indurated in some 
points and evidently. softened in others ; and these two altera- 
tions may even exist simultaneously in the parietes of the same 
ventricle. 



§ II. Softening. 



This alteration may be confined to the internal membrane 
of the heart, or may affect the whole of its muscular structure. 
The softening-of the internal membrane may be either general 
or partial ; and in either case the part affected may be of a red 
or of a pale colour. The softening of the muscular tissue con- 
stitutes what is, strictly speaking, termed softening of the heart. 
The heart, when thus affected, is remarkable for its great flac- 
cidity, is easily torn asunder, and is sometimes so remarkably 
friable, as to allow the finger to pass through its substance on 
the slightest pressure. The colour of the heart when in a state 
of softening is very variable : it is in some cases of a bright 
violet, in others remarkably pale, and in others of a peculiar 
yellow tinge, compared by Laennec to the colour of dead 
leaves. The same pathologist has remarked the first of these 
colours (violet), co-existing with softening of the heart in cases 
of severe fever. The pale colour is less common than either 



DISEASES OF THE HEART. 199 

of the others, when the softening is at all considerable ; on one 
occasion, however, I found the heart as pale as a piece of 
fibrine from which all colouring matter had been washed away, 
and at the same time so softened that my finger passed through 
its parietes on a very slight pressure. Laennec states that he 
has frequently observed the white softening of the heart in ca- 
ses of pericarditis ; but the cases which he records are exam- 
ples of great flaccidity rather than of softening. 

The softening of the heart may be either. general, or partial. 
It may be confined to the parietes of one cavity, to the septum 
of the ventricles, or may affect several isolated points. These 
softening points may often be recognized by their peculiar 
colour, even before they are touched. In some cases, there is 
not the least appearance of softening on the external or inter- 
nal surface of the heart, but, when cut into, its substance pre- 
sents several points thus affected. Softening of the heart 
occssionally co-exists with the hypertrophy of its parietes, and 
the dilation of its cavities. 

According to Laennec, we may expect to find the heart soft- 
ened in those cases where dilatation of that organ has been 
accompanied by long and repeated attacks of suffocation; 
where the mortal struggle has been protracted for several 
weeks; and where the violet colour of the face and extremities 
has announced long before death the stagnation of the blood in 
the capillary system. I do not mean to deny that the heart 
may occasionally be found softened after this series of symp- 
toms, but I can affirm from my own experience, that it by no 
means necessarily follows. There is another assertion of 
Laennec's, which I think requires further confirmation before 
we can admit it as weli established, namely, that the yellow 
softening of the heart is generally accompanied by a certain 
degree of cachexy. 

Softening of the heart may, like that of other organs, succeed , 
to an attack of irritation; but it is absurd to suppose that the 
pre-existence of irritation is indispensably requisite to its form- 
ation. Compare the muscles of a man who dies suddenly of 
apoylexy, with those of a person exhausted by consumption: 
what an extraordinary difference* will you find in their consist- 



200 DISEASES OF THE HEART. 

ence and density, and yet how little of that difference is caused 
by irritation ! In fact, there is no immediate connexion what- 
ever between the irritation and the softening of a muscle: in 
this, as in other cases, the effect of irritation is to cause a devi- 
ation from the natural healthy action of the part; but such a 
deviation may be effected by a variety of other causes. 

In the present state of our knowledge, we may admit the 
following species of softening of the heart, founded on the cir- 
cumstances which precede or accompany its developement. 

1st Species. — Softening connected with active hyperaemia of 
the heart. 

2nd Species. — Softening connected with anaemia of the 
heart. 

3rd Species.— -Softening connected with atrophy of the 
heart. 

4th Species. — Softening connected with an acute alteration 
in the general nutritive process (as in typhus). 

5th Species. — Softening connected with a chronic alteration 
in the general nutritive process (as in a variety of chronic 
diseases). 

6th Species. — Softening, which we are not as yet enabled to 
refer to any morbid condition of the heart itself, or of the rest 
of the system. 



§ III. Solutions of Continuity. 



Ulceration of the heart is comparatively a rare affection ; it 
may either attack its internal membrane exclusively, or may 
extend into its parenchyma; in the latter case, the ulcers may 
be either superficial, or may burrow so very deeply as to have 
their bottom formed by a thin stratum of muscle, or even by 
the pericardium itself, and in some cases this membrane too is 
destroyed and the ulcer is thus converted into a perforation. 

We are not, however, to suppose that this is the only way in 
which perforations of the heart are produced. They may suc- 
ceed to other morbid alterations, such as softening, either local 



DISEASES OF THE HEART. 201 

or general, or may even take place without exhibiting any ap- 
preciable lesion whatever. 

Cases have been recorded, in which rupture of the heart has 
been said to succeed to falls or violent efforts : it has also been 
observed, in some few instances, to follow a violent shock or 
strong mental emotion: I can hardly conceive such a cause suf- 
ficient, unless where the heart was predisposed to rupture by 
some preceding lesion. 

Theory would lead us to suppose that it is in those points 
where the heart is thinnest, that it is most liable to rupture ; 
experience, however, proves the contrary; for the middle part 
of the walls of the left ventricle is, of all parts of the heart, the 
most frequently ruptured, whereas perforations of the right 
ventricle are exceedingly rare, and of the auricles still more so. 

In the neighbourhood of the perforation, the heart may pre- 
sent any of the following conditions: 1. it may be exempt 
from any appreciable alteration whatever; 2. it may be soft- 
ened to a greater or less extent round the perforation; 3, it 
may be in a state of hypertrophy, with, or without softening ; 
or, 4. it may be ulcerated in several points. In this last case, 
which is by no means uncommon, several ulcers are found, 
either in the vicinity of the perforation, or in some other part 
of the heart, burrowing to various depths, some eating entirely 
through the muscular substance, and reaching the pericardium, 
which then comes into immediate contact with the blood. At 
a recent meeting, I exhibited to the Academic Royale de Mede- 
cine, a heart which had five perforations in the posterior sur- 
face of its left ventricle; its muscular tissue had no appear- 
ance of softening. 

Perforation of the heart is generally followed by sudden 
death, not in consequence of the haemorrhage which ensues, 
for the pericardium necessarily limits its quantity ; indeed, in 
several cases of this description which I examined, I found 
only a small clot of blood, not even sufficient to distend the 
cavity of the pericardium. It is most probable that death is 
caused in these cases by the violent shock to the whole system, 
produced by the sudden derangement of the heart's functions. 
Of the individuals who died under my care, in consequence of 
Vol. II. 27 



202 DISEASES OF THE HEART. 

rupture of the heart, some had for along time previously mani- 
fested the usual symptoms of organic disease of that organ ; 
others had never betrayed any symptom of disease either of 
the heart or large vessels ; and others, again, had complained 
occasionally of uneasiness or pain in the precordial region, un- 
attended with any other morbid symptom. 

Instead of ensuing, as it generally does, almost instantane- 
ously, death in some cases does not take place for several 
hours, or even days, after the accident, in which case the per- 
foration is found plugged up by a coagulum of fibrine. Is it 
possible that this coagulum could become the medium for form- 
ing a true cicatrix, as in wounds of arteries, and, consequently, 
that perforation of the heart is not necessarily mortal ? 

Perforations of the heart from penetrating wounds do not 
differ in any essential particular from those we have already 
described. A remarkable case of this description is related by 
M. Dupuy,* in which the penetrating instrument first passed 
through the stomach, and afterwards pierced the heart : the 
animal (a bull) lived fourteen days after the injury. 

Besides the species of rupture already enumerated, there is 
yet another to which the heart is liable, namely, that in which 
the rupture is situated in the chordae tendinae, or in the carneae 
columnse. Corvisart relates three cases of one of the chordae 
tendineae being torn across during violent efforts ; and Laen- 
nec mentions his having found one of the tendons of the 
mitral valve ruptured in an individual affected with hypertro- 
phy and dilatation of both ventricles ; one of the other tendons 
was likewise remarkably thin and delicate near its valvular ex- 
tremity. Lastly, in a young woman labouring under phthisis, 
M. Bouillaud found one of the columnar carneae into which the 
tendons of the tricupsid valve were implanted, ruptured right 
across. 

Solutions of continuity of the heart may likewise commence 
at its external surface and proceed from the pericardium in- 
wards. One of the most interesting cases of this description 



* Journal de Medecine Veterinaire, par Dupuy, Amide 1826, p. 24. 



DISEASES OP THE HEART. 203 

on record, is to be found in the Memoirs de la Societe Roy ale 
de Medecine for the year 1776. A young woman, aged twenty- 
two, was sent for disorderly conduct to the House of Refuse 
at Perpignan. She was then suffering from a sense of weight 
and uneasiness in the cardiac region. She had likewise leucor- 
rhea, chancres on the vulva, and condylomata round the anus. 
Under the mercurial treatment the syphilitic symptoms disap- 
peared, but the sense of uneasiness in the chest still continued, 
and about six months after her admission she began to com- 
plain of an acute lancinating pain darting from the outer side 
of the left breast to the middle of the sternum. The pulse be- 
came small, frequent, and irregular, and was even altogether 
suspended for several seconds while the pain was particularly 
violent. The patient continued in this state of suffering for 
two years, and then sunk under it. On dissection, the heart 
appeared carcinomatous, the pericardium was completely 
sloughed away, and the external surface of the posterior side 
of the heart was occupied by a large ulcer, the bottom of which 
was formed by a thin layer of muscular fibres, so soft and fri- 
able as to break down under the slightest pressure from the 
finger. All round the ulcer the heart was remarkably indu- 
rated, and presented the usual characters of scirrhus. The 
circumference of the heart just below the auricles was eleven 
inces eight lines, and that of the ulcer, nine inches two lines 
and a half. 



CHAPTER III. 



Congenital Malformations. 



The greater part of these lesions proceed from an arrest of 
developement, and represent the different conditions of the 



204 DISEASES OF THE HEART. 

heart as it is found in the various gradations of the animal series, 
or in the human embryo, at the different stcges of its evolution. 
The congenital malformations of the heart may be classed 
as follows: 

1. Absence of the heart. 

2. Imperfect developement of the heart. 

3. Excessive developement of the heart. 

After describing these several alterations, I shall notice the 
unnatural directions and situations of the heart. 



§. I. Absence of the Heart, or Acardia. 



There is a period in the evolution of the embryo, when no 
trace of the heart is perceptible, though blood vessels can be 
distinctly perceived. This state of the parts, which is natural 
at an early period of foetal existence, is occasionally found 
much later, and even after the ninth month. In place of the 
heart, which in such cases is altogether deficient, there is some- 
times found a vascular network, unconnected with any large 
vessel, as in zoophytes; sometimes the umbilical vessels alone 
are found, communicating in the body of the foetus with some 
minute vascular ramifications; and lastly, the umbilical vein is 
in some instances found to communicate directly with the arte- 
rial system. 

Almost all the cases of acardia hitherto observed have been 
in foetuses wanting the brain and spinal cord; and it is a re- 
markable fact, that the heart is almost invariably wanting in 
acephalous monsters. Indeed, so well is this fact now estab- 
lished, that in a dissertation on acephalia, published by Elben, 
(Berlin, 1821,) the term acephalia is used as synonymous with 
acardia, the title of his treatise being "De acephalis, sive mon- 
stris corde carentibus, dissertatio." 

The heart may, however, though much more rarely, be want- 
ing in foetuses provided with a brain and spinal marrow. A 
well authenticated case of this description is fully detailed in 
the 2nd volume of the Repertoire d' Anatomie, fyc. In the 



DISEASES OF THE HEART. 205 

place usually occupied by the thoracic viscera, nothing was to 
be found but a sac filled with water; there was neither heart 
lung, trachea, vena cava, aorta, nor thymus; the ribs were well 
formed. The" brain, cerebellum, and medulla oblongata, pre- 
sented their natural appearance : the optic nerve was wanting, 
as was likewise the olfactory ; and both the eyes and nose were 
imperfectly developed. The alimentary canal likewise pre- 
sented several malformations. 



§. II. Imperfect or irregular Developement of the Heart, or 
Atelocardia. 



Almost every variety of form which the heart presents in 
the different gradations of the animal series has been observed 
in the human subject. 

A. A single auricle and ventricle; the pulmonary artery 
given off by the aorta. 

B. Two auricles divided by an imperfect septum; a single 
ventricle ; the pulmonary artery and aorta each arising sep- 
arately from the ventricle. 

C. Auricles imperfectly divided ; two ventricles, their sep- 
tum first begins to appear at the apex of the heart, and grad- 
ually extends towards its base. 

Separation of the ventricles perfect, that of the auricle in- 
complete ; foramen ovale open. This latter malformation not 
unfrequently co-exists with the absence or imperfect develope- 
ment of the septum of the ventricles. 

E. The right auriculo-ventricular orifice wanting; foramen 
ovale and ductus arteriosus open. 

These different degrees of imperfect developement of the 
heart frequently co-exist with other malformations, likewise 
produced by imperfect developement ; but they are also found 
co-existing with the malformations of other parts arising from 
an opposite cause, namely, excess of developement; as if the 
nutritive process, in order to compensate for its excess in one 
part of the body, was deficient in another. Thus, in those fee- 



206 DISEASES OF THE HEART. 

tuses which have almost all the organs double, we not unfre- 
quently find the heart consisting of a single auricle and ventricle, 
or perhaps of two auricles and one ventricle. In some cases 
of double foetus, two aortas or two pulmonary'arteries arise 
from a single ventricle. 

The heart may, however, be imperfectly developed in indi- 
viduals who are perfectly formed in every other respect. In 
this case, the malformation is not necessarily incompatible with 
life, as is proved by the circumstance of our not unfrequently 
finding the septum of the auricles or of the ventricles deficient 
to a greater or less extent in the bodies of adults, or even el- 
derly persons. In all such cases, there must necessarily have 
been a mixture of the venous with the arterial blood ; notwith- 
standing which, the disease termed cyanosis does not always 
accompany the malformation. 



§ III. Excessive Developement of the Heart. 



The heart, instead of being arrested in the progress of its 
evolution, may have its developement preternaturally increased, 
and thus present any of the following malformations. 

A. A supernumerary cavity, forming a sort of accidental ap- 
pendage to one of the auricles or ventricles, and communi- 
cating with the cavity of the part to which it is attached. 

B. A supernumerary septum, forming an imperfect division 
of one of the natural cavities. 

C. A second cavity completely partitioned off" by one of 
these septa, and giving off supernumerary vessels which com- 
municate with the regular vessels of the heart. 

D> Supernumerary auricles and ventricles. I have seen a 
heart with three auricles, and another with four ventricles. 

E. All the parts of the heart double. In this species of 
malformation there are really two hearts ; but their arrange- 
ment is liable to considerable variety. Thus, they may be 
both enclosed in one pericardium, and united together, their 
cavities either communicating or not. Sometimes the two 



DISEASES OF THE HEART. 207 

hearts have each a pericardium of its own, and are united at 
their apex, or remain isolated and distinct from each other. 
We very rarely find any of these varietes of double heart, ex- 
cept in those monsters which have all the other parts double. 
There are, however, a few exceptions. Winslow relates a 
case in which a double heart was found in a single thorax, while 
the oesophagus and trachea were wanting, and the foetus had 
cyclopia. This case is precisely the reverse of that of double 
monsters with a single heart. 



§ IV. Alterations in the Line of Direction of the Heart. 

M. Breschet has seen four instances of the natural direction 
of the heart being so altered, that the organ might be said to be 
in the right side of the thorax, the apex occupying at the right 
side the position it generally maintains at the left. The sub- 
jects of these observations were young infants, otherwise well 
formed. This malformation is not always congenital : it may 
be produced by a variety of causes, such as an accumulation 
of fluid in the left pleura, which sometimes causes the heart to 
assume a vertical position and occupy the median line, and 
sometimes thrusts it over, so that the apex pulsates against the 
ribs of the right side. 

§ V. Displacement of the Heart. (Ectopia cordis.) 



We have a great number of cases on record of the heart's 
being situated out of the thorax, and occupying a place at a 
greater or less distance from its natural situation. In one case, 
it has been seen forming an anomalous tumour in the neck ; in 
another, it has been found in the abdomen : Dr. Deschamps de 
Laval* relates an instance of the heart's being found below the 



* Journal general de Medecine, torn. xxvi. 



208 DISEASES OF THE HEART. 

diaphragm, occupying the place of the left kidney ; the aorta 
and other vessels passed through the diaphragm, and assumed 
their natural position in the thorax. The individual in whom 
this remarkable malformation was observed was a middle aged 
man. In the Journal of the Medical Society of Bordeaux for 
1825, is detailed the history of a female infant, who at her birth 
had a pulsating tumour extending from under the false ribs to 
the umbilicus : she lived two years and a half. On examina- 
tion after death, it was found that the tumour was formed by 
the heart, which thrust the diaphragm down before it, and 
reached with its apex to the umbilicus. 

A still more extraordinary malformation is where the heart 
approaches the head; as in the case recorded by Beclard,* 
where the heart was situated immediately under the palate. 

There are also many cases of ectopia of the heart, which 
proceed altogether from a defective developement of the tho- 
racic parietes : thus, when the sternum or a portion of the ribs 
is deficient, the heart protrudes through the aperture ; and 
when the diaphragm and abdominal parietes are also wanting, 
we find only one large tumour, containing the abdominal vis- 
cera in its superior portion, and the thoracic in its inferior. 



CHAPTER IV. 



LESIONS OF SECRETION. 



In the natural or healthy state, the only secretions which 
take place in the heart are, the secretion of fat between its mus- 
cular fibres, and the insensible exhalation of serous fluid, such 



* Bulletins de la FaculU de Mtdecine, torn. ii. 



DISEASES OF THE HEART. 209 

as is constantly going forward in every part of the living body. 
Hence we have naturally two orders of the lesions of secre- 
tion ; one consisting in a modification of the fatty exhalation, 
the other in a modification of the serous exhalation. 



ARTICLE I. 



LESIONS OF THE FATTF EXHALATION OF THE HEART. 



There is a certain quantity of fat naturally deposited round 
the heart. In chronic diseases, where the general emaciation 
is considerable, this quantity is diminished, or even totally dis- 
appears. On the other hand, the quantity of adipose matter is 
sometimes excessive ; and it then penetrates between the mus- 
cular fibres of the heart, which, in consequence become pale 
and wasted. This has been called the fatty degeneration of 
the heart, though in reality the muscular fibres are not con- 
verted into fat, but are only less apparent than usual, in conse- 
quence of the excessive deposition of fat between them. In 
some cases, however, it would appear that the muscular fibre 
itself had undergone a fatty transformation, a matter capable 
of greasing paper and the scalpel being found not only between 
the fibres, but infiltrating their texture. I have never myself 
seen this transformation of the muscular fibre into fat, but at 
the apex of the heart ; neither has Laennec seen it except in 
the same situation, or in other very circumscribed spots. It is 
accompanied by a yellow tinge like that of decayed leaves. 

It has been laid down, that persons whose heart is in a state 
of atrophy, and at the same time overloaded with fat, are more 
liable than others to die of perforation of that organ. A case 
in favour of such an opinion is given in M. Bouillaud's work. 
A priest died suddenly, and on examination it was found that 

Vol. II. 28 



210 DISEASES OF THE HEART. 

there was perforation of the right auricle, and that the whole 
heart was " prodigiously fat :" no mention is made of the state 
of the muscular fibres. The accumulation of fat about the 
heart was at one time considered a cause of asthma and sud- 
den death ; and such may be the case, but as yet we require 
proofs of the fact. 



ARTICLE II. 



LESIONS OP THE PERSPIRABLE EXHALATION OF THE HEART. 



This exhalation is to be considered, 1. in the parenchymatous 
substance of the heart ; and, 2. on the surface of its cavities. 



§ I. Lesions of the Perspirable Exhalation in the Parenchyma 
of the Heart. 

The quantity of perspirable fluid which the cellular tissue 
of the heart exhales is sometimes so much increased, as to 
produce a serous infiltration, a true oedema of that viscus. 
M. Bouillaud, who has described this morbid appearance, has 
only seen it in cases of general dropsy, and attributes it to the 
the same causes as produced the general affection. 

Instead of the perspirable fluid, we sometimes find separated 
from the blood certain morbid productions, both solid and fluid. 
These, like the perspirable fluid itself, may be deposited either 
on the surface or in the substance of the heart. 

The simplest of these productions consists of a white sub- 
stance, without any trace of organization, which is frequently 
deposited on the surface of the heart, where it presents the ap- 
pearance of a dirty white patch : its seat is evidently in the 



DISEASES OF THE HEART. 211 

fine cellular tissue that unites the heart to its enveloping mem- 
brane. As this white substance increases in thickness, it as- 
sumes more and more the appearance of cartilage. It is also 
deposited, and even more frequently than in the preceding sit- 
uation, between the reflections of the internal membrane that 
compose the valves, and here it is peculiarly apt to become in- 
crusted with the calcareous phosphates. 

The deposition of saline matter in this morbid secretion has 
been improperly denominated by some authors ossification of 
the heart : this term should be restricted to those cases where 
the heart itself, or one of its component tissues, is converted 
into bone. 

The true ossiform degeneration of the heart may be divided 
into three species, according as it is situated in the cellular, 
fibrous, or muscular tissue. 

The first and most common species of ossiform degeneration 
has its seat in the cellular tissue that unites the several anatom- 
ical elements of the heart together. In this tissue, the cal- 
careous phosphates are deposited, either in the form of minute 
grains, or of masses of considerable bulk. These grains or 
masses are deposited between the tissues, which they separate 
and compress, but do not destroy. They occur most frequent- 
ly in the neighbourhood of those parts where fibrous tissue 
exists, such as round the orifices of the auricles and ventricles, 
along the chordae tendinese of the mitral valve, and in the sub- 
stance of the aortic valves. They are also observed, but more 
rarely, in the fleshy substance of the heart, where they either 
form isolated tumours, or are connected by prolongations of 
the same matter with other calcareous deposits formed round 
the orifices. 

The second species of ossiform degeneration of the heart is 
seated in the fibrous tissue, which then appears actually trans- 
formed into calcareous matter, though it never presents the 
outward appearance or the internal texture of the true bones. 
This transformation occurs chiefly in three points: 1. in the 
tendinous zone that encircles the left auriculo-ventricular 
orifice, which is thus converted into a bony ring ; 2. in the 
valves ; when ossification of the valves arises from this trans- 



212 DISEASES OF THE HEART. 

formation, the calcareous matter does not appear in irregular 
masses, but is situated within the valves, and observes the 
same arrangement as the fibrous tissue itself did ; 3. in the 
tendons that unite the mitral valve to the columns; carnea; of 
the left ventricle. 

The third species of ossifornrdegeneration, which is by far the 
rarest is seated in the muscular tissue. In some cases it is confin- 
ed to one of the columnae carnea; ; in others, it involves a consid- 
erable extent of the muscular substance of the parietes. Exam- 
ples of this perfect conversion of the muscular substance into 
bone are so few, and those so vaguely described, that additional 
observations are desirable before the fact is definitively admitted. 
One of the most remarkable cases of this description is that re- 
corded by M. Renauldin.* In a man thirty three years of 
a»e, the heart was found remarkably hard and heavy. On at- 
tempting to cut into the left ventricle, considerable resistance 
was experienced, in consequence of the perfect conversion of 
its parietes into a petrified mass, which had in some parts a 
o-ritty, mortar-like appearance, and in others resembled a saline 
crystallization. This mass of calcareous matter extended from 
the surface of the ventricle to its columnar carneas, which were 
likewise petrified, and considerably enlarged, but retained their 
natural form. Many of them were as thick as the tip of the 
little finder, and resembled so many stalactites lying in differ- 
ent directions. The temporal and maxillary arteries, and a 
portion of the radial, were ossified on each side. The difficul- 
ty in these cases is to ascertain whether the calcareous matter 
is deposited in the muscular fibre itself, or in the cellular tissue 
which unites these fibres. 

It still remains to be explained why the ossiform degenera- 
tion is almost exclusively confined to the left side of the heart, 
although the structure and organization of both sides seem pre- 
cisely the same. Another circumstance which we are equally 
at a loss to account for, is the frequency of this degeneration in 
old age, and its comparative rarity before the age of fifty or 



* Journal de Corvisart, Janvier, 1816. 



DISEASES OF THE HEART. 213 

fifty-five.* It is one of those striking examples, of which we 
possess so many, of the subordination of local affections to cer- 
tain general modifications of the system. 

The morbid productions just enumerated are found only in 
the heart, and never in any other part of the body; but there 
are others to which the heart is liable in common with every 
part of the body where cellular tissue exists. Of this descrip- 
tion are the purulent connections which are sometimes found 
in that organ, varying in size from that of a pea to that of a 
hen egg. The tissue of the heart immediately around these 
purulent deposits is in some cases redder than natural, and soft- 
ened ; in others it appears perfectly healthy. 

Abscesses of the heart are of two sorts: the one produced 
by a morbid condition of the heart itself ; the other occurring 
only in those cases where there has been a suppurative process 
going forward in some other part of the body, from which the 
pus is absorbed into the circulation, and subsequently deposit- 
ed in different points of the system. A short time since, my 
friend M. Reynaud shewed me a heart which had several col- 
lections of pus in the substance of its parietes, and at the same 
time had a considerable quantity of the same fluid mixed with 
the blood contained in its cavities. 

The old authors make frequent mention of abscesses of the 
heart ; but an attentive perusal of their descriptions is suffici- 
ent to convince us that they mistook for abscesses, simple col- 
lections of pus in the sac of the pericardium. These collec- 
tions are, however, sometimes accompanied by a true suppura- 
tion of the heart itself. Tn a little girl ten years old, whose 
pericardium was filled with pus, I found an abscess the size of 
a nut in the parietes of the left ventricle, completely isolated 
from the collection in the pericardium. Laennec likewise 
found a small abscess in the left ventricle of the heart in a 
child who died of pericarditis. 

The morbid productions known by the name of tubercles, 
scirrhus, and encephaloid, are also found occasionally in the 



* Vide Clinique Medicate. 



214 DISEASES OP THE HEART. 

heart. Laennec only saw three or four cases of tubercles in 
that organ, it being one of those in which they are most rarely 
developed : indeed, so far as my experience goes, they are 
never found there but when they exist at the same time in 
several other organs. 

Scirrhus and encephaloid are of almost as rare occurrence in 
the heart as tubercle is. MM. Bayle and Cayol state, in the ar- 
ticle on cancer, in the Dictionaire des Sciences Medicales, that 
they have never seen an instance of scirrhus of the heart. La- 
ennec* saw but two cases of encephaloid of the heart: in one, the 
morbid matter formed several masses in the muscular substance 
of the ventricles ; in the other it was deposited in layers from one 
to four lines thick, along the coronary vessels. M. Recamier 
found the heart partially converted into a sabstance like the 
skin of bacon in an individual who had also cancerous tumours 
in the lungs. M. Cruveilhier f saw a number of encephaloid 
masses in the substance and on the surface of the heart of an 
old man. M. Rullier found almost the entire substance of the 
heart degenerated into a scirrhous mass, which formed irregu- 
lar knobs (" bosselures") on the external and internal surface of 
the heart: there was also a carcinomatous tumour in the me- 
sentery. M. Olivier, in his work on the spinal marrow relates 
another case of the encephaloid degeneration of the heart. 
M. Velpeau has published a remarkable case of encephaloid 
tumours deposited in the substance of the heart : similar tu- 
mours were also found in the lungs, between the pleura and 
ribs, in the bronchial glands, under the mucous membrane of 
the stomach, in the duodenum, in the pancreas, in the right 
kidney, in the liver to the amount of several hundreds, between 
the tunics of the gall-bladder, in different parts of the perito- 
neum, on the upper surface of the brain, in the thyroid gland, 
and lastly, under the skin and in the muscles of the right thigh. 

I have myself twice seen the lesion of which I have quoted 
so many examples : in both instances, the right side of the 



Traite de V Auscultation, edit. torn. ii. p. 570. 
f Essai sur VJlnatomie. Pathologique. 



DISEASES OF THE HEART. 215 

heart was the part affected. In the first case, the patient, who 
was fifty-six years old, presented only the usual symptoms of 
hypertrophy of the left ventricle, which, on dissection, he was 
found to have. In addition to this, almost the whole of the 
walls of the right ventricle and auricle were converted into a 
hard, dirty-white substance, traversed by a number of reddish 
lines, and possessing all the characters of encephaloid. It was 
really surprising in this case how the right auricle and ventri- 
cle were capable of propelling their contents, and keeping up 
the circulation. 

In the second case that fell under my observation, the depo- 
sition of encephaloid matter was not so extensive. The exter- 
nal wall of the right ventricle was occupied by a large knotted 
tumour, extending from its apex to its base, which projected so 
far externally as to lead us to mistake it for a supernumerary 
heart, and likewise protruded internally into the cavity of the 
ventricle. When divided, it was found to be composed of the 
substance named encephaloid, in some points hard, and in 
others, soft and diffluent. The patient was thirty-seven years 
old at the time of his death, and had enjoyed good health until 
two years previously, when he became slightly asthmatic ; in 
this state he continued for five or six months, when he was 
suddenly seized one morning after breakfast with the most ex- 
cruciating pain, at first confined to the region of the heart, but 
soon extending over the whole left side of the thorax. At the 
same time, his dyspnoea increased, and he had violent palpita- 
tions and vomiting ; after an hour the pain abated, and the next 
day he was as usual. During the following year his difficulty 
of breathing gradually increased, and he had seven or eight re- 
turns of the same pain, which he compared to that of violent 
tooth-ache. At the time of his admission into La Charite, he 
was considerably emaciated, his face had a peculiar sallow 
tinge, and every evening there was a slight accession of fever. 
During the first month after his admission he had repeated at- 
tacks of violent pain of short continuance. He had occasion- 
ally violent palpitations ; but in the interval between those at- 
tacks there was no stethoscopic evidence of disease either in 



216 



DISEASES OF THE HEART. 



the heart or lungs. He lingered out a few weeks longer, be- 
came cedematous, and died suddenly without any struggle. 

To conclude the enumeration of these cases, M. Billard* found 
in an infant only three days old, three tumours imbedded in the 
heart, and possessing all the characters of scirrhus. 

The only other morbid productions that have as yet been ob- 
served in the heart are serous cysts, and hydatids. 

The serous cysts vary in size from that of a pea to a large 
hen-egg. Their general situation is between the external sur- 
face of the heart and the pericardium, but they are sometimes 
seen projecting from its internal surface. M. Dupuytrenf saw 
a number of these cysts imbedded in the walls of the right 
auricle, and protruding a considerable way into its cavity. In 
other cases, these cysts are not visible on the external or inter- 
nal surface of the heart, and it is only on dividing the muscle 
in which they are imbedded that we discover their existence. 
I have seen myself but one case of this description : the cyst, 
which was as large as a walnut, was imbedded in the side of 
the left ventricle, which was slightly affected with hyper- 
trophy. 

The only instance, I believe, on record, of these cysts being 
developed on the free surface of the lining membrane of the 
heart, is one which fell under my own observation. A small 
serous cyst, about the size of a nut, was attached to the inter- 
nal surface of the right ventricle, near its auricular orifice, by a 
delicate pedicle, apparently of the same texture as the internal 
membrane. 

The developement of serous cysts in the heart has been no- 
ticed by almost all the old writers on morbid anatomy. 

Instead of simple cysts, we sometimes find that species of 
hydatid known by the name of cysticercus. I have frequently 
seen it in the hearts of measly pigs, and once only in the human 
subject. On examing the heart of a person that died at La 
Charite, I found three small vesicles, each about the size of a 



; Traite des maladies des nouveau-nis, fyc. page 647. 
t Journal de Corvisart, fyc. torn. v. page 139. 



DISEASES OP THE HEART. 217 

nut, and perfectly transparent, with the exception of one white 
point, which, by pressure, was made to protrude like a head 
from the interior. 



§ II. Lesions of the persjnrable Exhalation in the Cavities of 
the Heart. 



These alterations are few in number, and rarely met with. 
I do not know of any morbid productions being found in the 
cavities of the heart, except pus and false membranes ; and it 
is very difficult in many cases to decide whether the pus so 
found is really the product of inflammation of the lining mem- 
brane of the heart, or not, as it may be conveyed thither in the 
torrent of the circulation from some other part in a state of 
suppuration. 

False membranes are sometimes found lining portions of one 
or more of the heart's cavities. The surface underneath these 
layers is in some cases described as red ; in others, its colour is 
not mentioned. We should not confound with false mem- 
branes the pellicles which are often found lining the internal 
surface of the heart, as the latter are formed after death by the 
mere physical arrangement of a certain number of molecules 
of the blood in a state of stagnation. 



CHAPTER V. 



Lesions of the Blood contained in the Cavities of the Heart. 



All pathologists of the present day are agreed that some of 
the coagula found after death in the heart have been formed 
Vol. II. 29 



218 DISEASES OF THE HEART. 

there during the life of the individual. The great consistence 
of these coagula, their close adhesion to the substance of the 
heart, and, in some cases, their evident organization, fully es- 
tablish the fact that the blood may, during life, coagulate in the 
cavities of the heart, and there become the nidus of several 
morbid alterations. 

The intimate connexion that is formed between the coagu- 
lum and the heart is the simple consequence of a very general 
law, by virtue of which, two parts endowed with life cannot 
remain in contact without being united to each other, by a pro- 
cess somewhat resembling that by which grafting takes place 
in the vegetable kingdom. 

The formation of vessels in the coagulum is the result of 
another law in the animal economy, namely, that every particle 
of blood which remains in a state of stagnation in the living 
body has a constant- tendency to become organized. Two re- 
markable examples of the organization of these coagula are 
recorded by M. Bouillaud, in his very interesting essay on the 
obliteration of veins. In one of these, the right auricle was 
almost completely filled by a soft coagulum traversed in every 
direction by an infinite number of minute vessels, some of a 
bright red, and others of a dark colour. In the other, the right 
auricle and ventricle contained masses of albuminous and 
fibrinous matter, evidently organized, and connected with the 
parietes of their respective cavitives by filaments which it was 
necessary to tear before they could be detached. The individ- 
ual who formed the subject of this case died with all the symp- 
toms of aneurism of the heart. To these facts I shall add 
another, published by Doctor Rigacci in Italy, and noticed in 
the Bulletin des Sciences Medicates for September, 1828. — A 
lady had for several years presented the usual symptoms of 
aneurismal dilatation of the heart. On dissection, the left ven- 
tricle was found dilated, and its walls considerably attenuated. 
Its cavity was filled by a substance resembling flesh, which 
seemed to arise by two distinct roots, one implanted in the 
columns carnese, the other in the mitral valve. Three reddish 
filaments likewise passed from the columnae carnese, and en- 
tered the substance of the polypous mass: these had all the ap- 
pearance of blood-vessels, and, when injected with mercury, 



DISEASES OF THE HEART. 219 

were found to divide into a number of small branches that 
ramified through the substance of the polypus. By careful dis- 
section, it was ascertained that the tumour was formed alto- 
gether of a mass of fibrine, such as is found in the sac of arte- 
rial aneurisms. 

If once we admit that polypous concretions in the heart may 
become organized, it follows as a necessary consequence that 
they may have different morbid productions formed in their 
interior. Several instances have already been mentioned in 
this work, of pus having been found in these concretions; and 
though we may in some cases suppose that the pus was not 
actually formed in the coagulum, but only brought into the 
heart with the blood, in which it was circulating, yet there are 
others in which it is impossible to account for its presence in 
the coagulum, otherwise than by admitting its having been 
formed there. If, then, pus is formed in the interior of these 
polypous concretions, there is no reason why cartilaginous and 
osseous productions may not likewise be developed there. 
Burns found one of these polypi of the size of a hen-egg ossifi- 
ed in several points, and so perfectly organized, that, on inflat- 
ing the coronary vein, a number of minute vessels on the sur- 
face and in the substance of the tumour became distended with 
air. In another case mentioned by Cruwell,* a small globular 
body, principally composed of cartilage and bone, and contain- 
ing a cavity in its interior, was found wedged in between the 
valves of the pulmonary artery. This case was likewise re- 
markable as presenting one of the most extensive ossifications 
on record of the right side of the heart: under the lining mem- 
brane of the auricle and ventricle there were several plates of 
bone, which were prolonged into the fleshy substance of the 
ventricle; many of the columnae carneae were ossified; and 
both vena? cavse had several patches of osseous incrustation. 
It would seem in this instance that the blood which coagulated 
during life in the right side of the heart took on the ossific pro- 
cess, because, having once become solid and organized, it 



De cordis et vasorum osteogenesi in quadragenario observata. Halae, 1765. 



220 



DISEASES OF THE HEART. 



should, by a general law of the economy, participate in the life 
of the surrounding solids, and in their morbid conditions also. 

The fact of the organization of these concretions affords like- 
wise the most probable explanation of the mode of formation 
of those vegetations which are occasionally found on the inner 
surface of the heart, especially on the valves. Nothing can be 
more accurate than the description Laennec has given of the 
several phases through which these vegetations pass, from the 
period when they yet resemble an amorphous mass of fibrine, 
precisely such as is formed by a coagulum of blood, up to the 
time when they are traversed by vessels of their own, acquire 
their determinate form, and seem to be an excrescence from 
the membrane on which they are situated. 

It would be an endless task to attempt an enumeration of the 
different forms which these vegetations may present; I shall 
therefore only enumerate a few of the principal varieties, in 
order to show how productions originally the same may sub- 
sequently, by a simple modification of form, assume an aspect 
so totally different from each other, that it is only by an atten- 
tive examination of all the intermediate phases that the identity 
of their origin can be recognised. Thus, some of them bear a 
striking resemblance to venereal warts, others to those syph- 
ilitic productions named cauliflower excrescences, others are 
like strawberries, whilst others assume a cylindrical or a taper- 
ing form. Sometimes they appear as minute granular bodies 
closely studding over that portion of the lining membrane to 
which they are attached; in other cases, again, they assume the 
form of hollow globules or vesicles containing a variety of sub- 
stances in their interior, such as pure blood, either fluid or 
coagulated, a substance like the lees of wine, or, lastly, a puri- 
form matter, which is evidently nothing else than fibrine de- 
prived of its colour and altered in its qualities ; indeed this is 
one of the cases where we can most satisfactorily trace the 
transformation of fibrine into puriform matter. These vege- 
tations, whatever be their form, may be attached to the wall of 
the heart either by their surface, or by a neck of peduncle of 
variable length, which is generally entangled in the meshes that 
exist on the internal surface of the cavities. If we examine 



DISEASES OP THE HEART. 221 

the structure of these peduncles, we at once see that they are 
composed of fibrine, which generally retains more of its origi- 
nal character of a coagulum than the vegetations to which they 
are attached ; from whence we might in such cases reasonably 
infer that they are posterior to them in the date of their forma- 
tion. 

The colour and consistence of these vegetations furnish ad- 
ditional arguments in favour of the origin which we have 
assigned them: thus, they may be either red, brown, violet, 
deep yellow, or white (these, it will be recollected, are the dif- 
ferent shades which the blood presents on coagulating) ; the 
same vegetation may also be white externally and red inter- 
nally, or vice versa. Their degree of consistence is also ex- 
ceedingly variable ; some vegetations are so hard and firm as 
to cut like fibrous tissue, while others are so soft as to flatten 
like so much tallow under the pressure of the finger. But, 
what is particularly interesting for the solution of the question 
of their origin, is, that these vegetations not unfrequently pre- 
sent different degrees of consistence in different points : in some 
the blood is still fluid, in others, it is coagulated, but the coagu- 
lum is soft and coloured; a little farther on, the colouring mat- 
ter disappears, and the fibrine alone remains ; and this,in its turn, 
becomes organized, or else degenerates into a soft pulpy mass. 
Vegetations of the heart, as regards their connexion with 
that viscus, may be divided into three classes: those of the first 
are simply in contact with the surface on which they are laid, 
and such is the state of every vegetation at its commencement ; 
those of the second adhere to the heart either by simple fibrin- 
ous prolongations that extend into the meshes of the parietes, 
or by these prolongations become organized and incorporated 
with the substance of the heart itself; lastly, those of the third 
class, after having been adherent to the surface of the heart, 
are subsequently detached, and become loose and unattached 
as they were at the first period of their formation. I admit 
this last class, in order to account for those cases, where vege- 
tations of various forms and sizes have been found floating 
loose, and totally unconnected with the heart, but bearing on 
their surface a number of filaments which appeared as if they 



222 DISEASES OP THE HEART. 

had been torn across. It is highly probable that these filaments 
had, previously to their being ruptured, served to attach the 
vegetation to the surface on which it was originally formed. 
The older anatomists were of opinion that fibrinous concretions, 
when thus attached to the walls of the heart, might obstruct 
one of its orifices, and thus suddenly cause- the most fatal con- 
sequences: the modern doctrine, while it denies the possibility 
of such concretions being formed in the heart during life, as a 
necessary consequence rejects the idea of apprehending danger 
from such a source. I am, however, disposed to think that in 
this instance the old opinion will be found the more correct of 
the two. 

The causes which influence the formation of vegetations in 
the heart are not always easily appreciated ; in general, how- 
ever, they may be found either in the blood itself or in the heart. 

The blood may become so modified as to have a constant 
tendency to coagulate in the interior of the heart, whenever 
the circulation experiences the least impediment, or even in- 
dependently of any such impediment ; this will appear less sur- 
prising, when we recollect that the heart does not wholly dis- 
charge its pavities at each contraction, but that a certain 
proportion of blood remains behind, and is (as it were) filtered 
through, the meshes of the network which lines the internal sur- 
face of each of the heart's cavities. Certain morbid conditions 
of the heart may likewise favour the formation of these coagiila, 
by impeding the free passage of the blood through its cavities. 
Thus any alteration in the thicknes of the parietes, the dimen- 
sions of the cavities, or the structure of the orifices, must ne- 
cessarily produce a greater or less degree of stagnation of blood 
in the heart, and consequently afford a greater facility for its 
coagulation. In like manner, if the internal membrane be ir- 
ritated, and in consequence of that irritation throws out a coat- 
ing ofdymph, which renders its surface rugged and uneven, the 
blood, in passing over the uneven surface, will have a constant 
tendency to form depositions on it, as it does in the arteries, 
when their internal membrane has lost its natural polish. The 
explanation of this fact on mechanical principles is, perhaps, 
not altogether satisfactory; no doubt, however, can be enter- 



DISEASES OP THE HEART. 223 

tained of the fact, that wherever 1 the lining membrane of the 
sanguiferous system has been irritated and lost its natural pol- 
ish, it sooner or later becomes coated with a layer of coagulated 
blood. Whether the irritated part acts on the blood mechanic- 
ally or vitally, is in the present state of our knowledge difficult 
to determine; in the latter supposition, there is, however, no- 
thing more surprising, than in that singular modification of the 
blood, termed its bufly coat, which we so constantly observe in 
cases of pleuritis and inflammation of the joints. 



CHAPTER VI. 

Lesions of the Innervation of the Heart. 

As the diseases of this class do not depend on any alteration 
of structure cognizable to our senses, we must be contented 
with simply detailing the results of observation and experience, 
and shewing how, independently of any structural alteration of 
the organ, its functions maybe so deranged as to produce many 
of the same symptoms, and, in some cases, give rise to the 
same fatal consequences, as result from the different structural 
alterations enumerated in the preceding chapters. 

The heart may present unusual phenomena either in its con- 
tractility, or in its sensibility, which cannot be accounted for by 
any appreciable alteration in its organization : these phenomena 
we refer, in the present state of our physiological knowledge, 
to some derangement of that portion of the nervous influence 
which directs and regulates the action of the heart, as it does 
of every other part of the body. 

There are certain individuals who at intervals experience 
sensations of acute pain, or of numbness and weight in the re- 
gion of the heart; these sensations spread over the thorax, along 
the neck, the arms, especially the left, and sometimes along the 
course of the spinal nerves, and not unfrequently alternate 
with other pains seated in different parts of the body. I have 



224 diseases or the heart 

seen them in one woman alternate with tic douloureux, and in 
another succeed to intense headach, and in their turn be suc- 
ceeded by spasmodic contractions of the muscles in some parts 
of the body, loss of sensibility in others, globus hystericus, &c. 
This modification of the sensibility of the heart may either 
exist alone, or be accompanied by palpitations and dyspnoea. 
I once saw a case in which the latter symptom was so severe 
as to produce death. A woman was admitted into La Charite 
with diarrhoea and fever, who had had before her admission 
repeated attacks of acute pain in the region of the heart, ac- 
companied by palpitations and dyspnoea. A few days after 
her admission she was suddenly seized with most excruciating 
pain in the heart, which beat with extreme violence, and was 
audible all over the chest ; the pulse was irregular, the respira- 
tion became more and more laborious, and she died in a few 
hours after the attack, apparently in a state of asphyxia. On 
dissection, a few tubercles were found in the lungs, but neither 
the heart nor its appendages presented the slightest vestige of 
disease. 

This single case is of itself sufficient to establish the fact, that 
pain in the region of the precordia, accompanied by palpita- 
tions and dyspnoea, or, in other words, angina pectoris (as this 
group of symptoms has been named) may exist independently 
of any appreciable alteration in the organization of the heart. 
Not unfrequently, however, this affection snpervenes during 
the progress of organic disease of the heart : and I am inclined 
to think that in some cases it precedes the organic lesion, 
which, if my view of the subject be correct, should then be re- 
garded as its consequence, not as its cause. The theory of 
angina pectoris resulting from ossification of the coronary ar- 
teries is altogether unsupported by facts. Is there any more 
reality in the supposition of some connexion subsisting between 
this affection and the white spots which are sometimes found 
on the surface of the heart ? 

It will readily be admitted that a simple modification of the 
nervous influence, independently of any organic alteration, 
may so derange the heart's action as to cause palpitations ; 
for, who has not felt his heart palpitate under a strong mental 



DISEASES OF THE HEART. 225 

excitement? These nervous palpitations occur principally in 
three general conditions of the -economy, which it is important 
to distinguish carefully, as each requires a different plan of 
treatment. 

The first of these conditions is a state of plethora, which 
causes the heart to beat with too much force, just as it pro- 
duces vertigo, dizziness, &c. Low diet and copious venesec- 
tion are here indicated. 

The second of these conditions is a state of anaemia. Pal- 
pitations, accompanied by more or less of dyspnoea, are a fre- 
quent source of uneasiness to invalids who have been submitted 
to too severe a regimen, or kept too long on low diet : in all 
such cases, these symptoms are invariably relieved by the use 
of a more generous diet, which, we may suppose, acts by re- 
plenishing the blood, and invigorating the system. An anal- 
ogous case to the preceding is that of animals falling into con- 
vulsions from excessive haemorrhage. But there are likewise 
certain individuals who have neither been kept on too low diet, 
nor bled to excess, but who habitually and constitutionally 
make less blood than others, and are constantly subject to palpi- 
tations and dyspnoea connected with the anaemic state of their 
system. In such cases, shall we attempt to remove the palpi- 
tations by blood-letting, on the hypothesis of relieving a local 
plethora of the heart, of the existence of which we have no 
proof whatever ; or shall we not rather fulfil the evident indi- 
cation of restoring the balance of the system by endeavouring 
to increase the absolute quantity of the blood, or the relative 
proportion of its fibrine and colouring matter ? Certain it is, 
that under the treatment calculated to fulfil the latter indica- 
tion, we see those palpitations disappear, which would infallibly 
have been aggravated by venesection and low diet. 

Lastly, the third condition of the economy, which we have 
said is often accompanied by palpitations, does not depend 
either on an excess or deficiency of blood, for that fluid appears 
to exist in its due proportion, but on some primitive alteration 
in the action of the nervous centres themselves. In some cases 
of this kind, the palpitations are the only symptoms of the 
morbid state of the nervous system ; in others, they are only 
Vol. II. 30 



226 DISEASES OF THE HEART. 

one of the derangements in which almost every organ in the 
body more or less participates: Let us take, for example, a 
young hysterical girl, in whom the most extraordinary de- 
rangements in all the functions succeed each other with the 
greatest rapidity. If we bleed her, we neither diminish the 
palpitations, nor alleviate the other symptoms of her complaint. 
If we give her tonics, our success is no better. What then re- 
mains for us to do, but to employ such means, whether med- 
ical or moral, as act neither by debilitating nor yet by strength- 
ening the system, but by substituting a new modification of 
the nervous system in the place of the old one. In this way, I 
conceive, may be explained the efficacy of matrimony in at 
once removing a whole train of morbid phenomena, which had 
been combated in vain by different articles from the Materia 
Medica. I do not so much allude to the physical effects of 
marriage, as to the moral influence it exerts on the mind of the 
young woman, by the various emotions it excites, and by the 
complete revolution it works in all her ideas, habits, and 
pursuits. 

Thus, then, there is a large class of affections of the heart 
of which morbid anatomy shews us little else than the termina- 
tion. That which we find in the dead body is not always what 
has been the first cause of the disease ; it is not the hypertro- 
phy of the heart which originally produced the palpitations, 
but, in many cases, the palpitations which produced the hyper- 
trophy. Hence the evident conclusion, which cannot be too 
often impressed on the mind of the morbid anatomist, namely, 
that the treatment of the disease, at least at its commencement, 
is not to be regulated so much by the morbid appearances 
found after death, as by the state of the system which preceded 
and favoured the developement of those morbid appearances. 



DISEASES OF THE ARTERIES. 227 



SECTION II. 



DISEASES OF THE ARTERIES. 



CHAPTER I. 



LESIONS OF CIRCULATION. 



We frequently find in the dead body the internal membrane 
of the arteries dyed a bright red colour : whence comes this 
peculiar appearance ? Is it the result of inflammation, or is it 
merely a post mortem alteration 1 The same arguments that 
were adduced at the commencement of the last section, when 
the same question was started with respect to a similar appear- 
ance in the heart, are equally applicable in the present instance. 
Whenever a body is opened in an incipient state of putrefac- 
tion, the internal coat of the arteries is invariably red ; and in 
proportion as the quantity of blood is considerable, and it evin- 
ces but little disposition to coagulate, this redness is more 
marked, and makes its appearance at a shorter period after 
death. In some cases, where the blood only covers certain 
points of an artery, the redness is confined to those points ; 
and lastly, it may be produced at pleasure by enclosing some 
blood in an artery, tying both ends, and allowing it to remain 
for some time. These facts are amply sufficient to prove that 



228 DISEASES OF THE ARTERIES. 

the uniform redness which is so often observed in the inner ar- 
terial coat may be produced by the simple circumstance of 
the blood soaking through, and imparting its colour to it. 

But then, on the other hand, there are some cases, where 
the same redness is observed on the arterial surface in bodies 
which do not yet betray the slightest symptom of putrefaction. 
It is found, too, under the most different circumstances, whether 
the artery be empty or full, whether the blood be fluid or co- 
agulated, and whether the coagulum be deprived of its colour- 
ing matter or not. Several of the dissections recorded by 
MM. Bouillaud and Bertin, in which they found the internal 
surface of the aorta red, were made within twenty-four hours 
after death, and during the cold season. 

Having premised these observations, we may now proceed 
to consider whether this red stained appearance is invariably a 
post mortem alteration, or whether it is in some cases produced 
during life. In the year 1825 a violent distemper prevailed 
among the horses at Paris and in some of the provinces : the 
most general symptoms were those of gastro-intestinal irrita- 
tion, but, with very few exceptions, the thoracic viscera were 
likewise implicated, the breathing being greatly affected, al- 
though there was not much cough. During this epidemic, 
M. Dupuy and I dissected a number of horses at the slaughter- 
houses at Montfaucon : the animals were scarcely slaughtered 
when we proceeded to examine them, and in many cases the 
internal membrane of the heart and aorta presented a bright 
red colour. At the same time. M. Bouley, jun., one of our 
most distinguished veterinaries, examined more than fifty horses 
who died of the same epidemic : his dissections were always 
made within from half an hour to three hours after the death 
of the animal, and in almost every instance he found the inter- 
nal membrane of the heart and aorta of a bright scarlet or pur- 
ple colour. On the other hand, MM. Rigot and Trousseau, 
who likewise opened a great number of horses, state that they 
never found any appearance of redness in the heart or arteries, 
when the dissection was made shortly after death, but that they 
always found it when the dissection was deferred for several 
hours. This difference in the result of our dissections is to be 



DISEASES OF THE ARTERIES. 229 

accounted for by the circumstance of our researches having 
been made at different periods, mine during the year 1825, 
theirs in 182(5, after the distemper had ceased. There is there- 
fore nothing extraordinary in the different results we obtained ; 
and it appears to me, that the very circumstance of the red- 
ness of the heart and arteries, so constantly observed during 
the first epidemic, not being -observed after it had ceased, af- 
fords an additional reason for supposing that it was produced 
by a morbid condition of the part. As to the nature of that 
morbid condition, I think it highly probable that it was an irri- 
tation of the coats of the arteries ; but I am well aware, it may 
be otherwise explained by supposing that the blood was so mod- 
ified during the lifetime of the animal, that its colouring matter 
separated from its fibrine, and stained the parietes of the heart 
and arteries. But then we should take into account, that 
these horses during their illness presented decided symptoms 
of disease in the thoracic viscera, and as no morbid appear- 
ance was found in the lungs, we have nothing to attribute those 
symptoms to but the affection of the heart and large vessels, 
characterized, 1. by the uniform red colour of their internal 
membrane ; 2. by a remarkable degree of softening in the mus- 
cular structure of the heart ; and, 8. by inflammation of the 
pericardium, and effusions of different kinds into its cavity. 

From these facts I conclude that the uniform redness of 
the internal coat of arteries may be in some cases the result of 
inflammation. In one of the cases recorded by M. Bouillaud, 
the internal membrane is described as being covered in those 
parts where it was red, by a thin layer of albuminous matter : 
surely this is tolerable evidence of the existence of inflamma- 
tion. 

The red colour thus produced differs in no respect from that 
which is developed after death. Several experiments have re- 
cently been made by Gendrin,* with the view of ascertaining 
whether the colour produced in the arterial coats by irritating 
them artificially was invariably the same uniform red stain, or 



* Histoire Jlnatomiqiit des Inflammations, torn. ii. p. 9. 



230 



DISEASES OF THE ARTERIES. 



whether they may not in some cases present appearances more 
analogous to those produced by irritation in other parts of the 
body. 

When he used a moderate degree of compression on an ar- 
tery, he found, at the end of twelve or fifteen hours, the in- 
ternal coat of a pale red, the middle of a reddish yellow, and 
the cellular sheath minutely injected : both above and below 
the part compressed, the outer and middle coat were uniformly 
reddish and infiltrated with serum, and the inner coat was of a 
brilliant red colour. After a lapse of thirty or forty hours the 
middle coat became evidently softened and injected, and imme- 
diately above and below the compression the external and mid- 
dle coats seemed confounded into a red flesh-like substance in- 
filtrated with blood and serum. 

In the second experiment, he injected some irritating sub- 
stance into a portion of artery included between two ligatures, 
and from which the blood had been previously washed out ; 
the internal membrane, after a few hours, was found to have 
acquired a bright violet colour. Now, in this case, it is evi- 
dent that the membrane could not have been stained by the 
blood, for at the commencement of the experiment that fluid 
was all washed away. 

Lastly, if we wash an artery, slit it open, and expose its in- 
ternal surface to the air, its inner membrane soon turns red, and 
the subjacent coats acquire a bright vermilion colour. 

From these facts it follows, that we can produce artificially 
in the arteries of living animals, the same varietes of colour as 
we sometimes find in the arteries after death. There is, how- 
ever, this important difference, that when the redness of the 
arteries is produced by artificial irritation, it is accompanied by 
other alterations of tissue, such as softening, serous or purulent 
infiltration, &c. ; whereas in almost all the cases where the 
arteries have been found of a red colour in the human subject, 
the change of colour was unaccompanied by any other morbid 
alteration. 



DISEASES OF THE ARTERIES. 231 



CHAPTER II. 



LESIONS OP NUTRITION. 



The different coats of which the arterial tube is composed, 
are not all altered in their nutrition in the same manner, or at 
the same time. It is therefore necessary to consider them 
apart, and to study in each tissue the alterations of nutrition to 
which it is liable. 

The internal membrane presents very few alterations. It 
sometimes loses its tenuity and natural transparency ; this al- 
teration may be confined to a few isolated points, producing 
the appearance of white spots dotting over the internal surface, 
or may extend over a considerable surface. The thickening 
and opacity of this membrane is, however, in many cases only 
apparent, and is really owing to an albuminous exudation de- 
veloped in its subjacent cellular tissue. 

Another alteration of nutrition to which the internal mem- 
brane is liable is softening ; it is sometimes found so friable, as 
to be reduced to a pulpy mass by the slightest scraping with 
the scalpel. 

Lastly, the internal membrane is subject to ulceration. The 
ulcers of this membrane are generally round ; sometimes only 
one is to be found in the whole arterial system, in other cases 
the aorta is almost riddled with them; this, however, rarely 
happens unless when they co-exist with other alterations in the 
subjacent tissues, such as ossification, &c. I recollect, howev- 
er, having seen one case in which the internal surface of the 
aorta was overspread with a number of round superficial ulcers, 
about the size of six-pences. The margins of some were mark- 
ed by a brown or rose-coloured zone, and their bottom was 
formed by the fibrous coat which appeared free from disease 
throughout. 



232 



DISEASES OF THE ARTERIES. 



The middle coat is more frequently altered ift^ts structure 
than the internal, and its alterations are much more varied. It 
sometimes becomes soft and friable, is readily torn by the slight- 
est effort, and loses its natural elasticity ; hence arise serious 
modifications in the functions of the artery, and likewise of the 
heart, if the loss of elasticity extends over an extensive surface. 

Hypertrophy is another alteration to which the middle coat 
is often liable. When in this state, its natural organization be- 
comes much more apparent : the yellow fibrous tissue of which 
it is composed, becomes as evident in the human subject as it is 
in the horse, but never does it present any trace of muscular 
fibre, even in the most extreme cases of hypertrophy. This 
alteration may extend over the whole surface of an artery, or 
may be confined to certain isolated points, which then form ir- 
regular protuberances on the internal surface of the artery. 

This coat may likewise fall into a state of atrophy, in which 
case it appears as if about to return to cellular tissue. The 
whole arterial tunic becomes much thinner, and resembles the 
tunic of veins, and the artery too loses its elasticity, and col- 
lapses when divided. 

Although the fibrous tissue of the arteries is never converted 
into muscular tissue, there are other transformations which it 
not unfrequently undergoes. In some cases its fibres acquire 
a considerable degree of rigidity, and are gradually transformed 
into cartilaginous or even osseous rings, which embrace the 
whole circumference of the artery. This transformation is 
rarely met with in the aorta, but occurs not unfrequently in the 
arteries which mediately arise from it : I have seen it, for in- 
stance, exceedingly well marked in the femoral artery, the pa- 
rieties of which presented a series of cartilaginous and osseous 
circles, and bore a striking resemblance to the parietes of the 
trachea in birds. 

Lastly, the middle coat is, like the inner one, subject to ul- 
ceration. 

The external or cellular membrane is liable to few alterations. 
It often remains intact when both the other coats are exten- 
sively diseased, and, when they are ruptured, it frequently re- 
mains to sustain the pressure of the column of blood with which 



DISEASES OP THE ARTERIES. 233 

it then comes into immediate contact. Sometimes, however, 
it participates in the disease of the other coats, and, like them, is 
ruptured, and allows the blood to escape. 

The several alterations of nutrition just enumerated, do not 
merely change the appearance and properties of the particular 
coat which they affect, but likewise generally produce an evi- 
dent alteration in the dimensions of the artery. In this way 
the caliber of an artery may be either increased, diminished, or 
totally obliterated. I shall consider each of these alterations 
separately. 

L Dilatation of the Arteries. 



An artery may be dilated in its entire circumference, or in 
only a part of it. 

The dilatation of the entire circumference is the more fre- 
quent case of the two : it may embrace a considerable extent of 
artery, as for instance, the whole of the aorta, or may be con- 
fined to one or more points where it forms so many circular 
bulges. 

The dilatation of an artery in a part only of jt^imimfergnce, 
is so rare an occurrence that some authors have questioned its 
reality ; the fact, however, is placed beyond dispute, for on 
more occasions than one I have been able to trace distinctly 
the three arterial coats passing over the walls of a sac which 
seemed as if appended to the artery, with the cavity of which 
it communicated. 

This dilatation of an artery without rupture of any of its coats, 
has received from authors the name of true aneurism. 

When an artery is dilated, its parietes, though not ruptured, 
may present various alterations. In some cases they are much 
thinner than natural, the middle coat loses its wonted elasticity, 
and the arteries then yield like veins to the distending force of 
the blood. In other cases, again, the arterial parietes are in a 
state of hypertrophy, thus furnishing an analogous case to the 
Vol. II. 31 



234 DISEASES OF THE ARTERIES. 

dilatations of the stomach and heart, which are often accom- 
panied with an increase of thickness in their parietes. 

In the preceding cases of dilatation, there has been no rup- 
ture of any of the arterial coats; but there is another form of 
the disease, the false aneurism of authors, in which the dilata- 
tion is accompanied by rupture of one or more of those coats. 
When the internal and middle coats are ruptured, the blood 
comes into immediate contact with the cellular sheath, which it 
gradually distends and dilates into the form of a pouch, known 
by the name of the aneurismal sac. 

The parietes of the sac are generally much thicker than the 
cellular sheath of which they were originally formed, in con- 
sequence of the surrounding cellular tissue becoming gradually 
so condensed as to form an additional envelope. The interior 
of the sac is more or less filled with coagulated blood, the co- 
agula being arranged in concentric layers, of which the outer 
ones in some cases acquire such a degree of density as to be 
confounded with the parietes of the sac. There is a constant 
process of irritation kept up all round the external surface of 
the sac, in consequence of which adhesions are formed that 
unite it more or less firmly to the surrounding parts. These 
parts are variously affected: sometimes they are mechanically 
compressed, or displaced, by the pressure of the aneurism, or 
even worn away by its pulsations, and in some cases they un- 
dergo a process of irritation which terminates in their ulcera- 
tion and destruction. Thus, when the aorta is the seat of the 
aneurism, the tumour may make its way through the sternum 
or the ribs, and protrude externally; M. Lenoble lately com- 
municated to the Academic de Medecine the particulars of a 
case in which the aneurism, after destroying the ribs, came in 
contact with the scapula, and displaced it very considerably. 
It may also attack the bodies of the vertebrae, eat its way 
through the spinal canal, and by pressing on the spinal cord, 
produce sudden paralysis: it is remarkable that the interverte- 
bral cartilages often remain uninjured in these cases. Some- 
times the aneurism presses against the organs contained in the 
thorax or abdomen, and in this way may compress or perforate 
the pulmonary artery, the superior cava, the thoracic duct, the 



DISEASES OF THE ARTERIES. 235 

oesophagus, the trachea, the bronchial tubes, the lungs, the 
stomach, or some convolution of the intestines. It may burst 
either in the pleura or into the peritoneum. The veins which 
run in the neighbourhood of aneurisms are often compressed, 
or even obliterated, the nerves are flattened like ribbands, and 
the muscles are wasted in a remarkable degree. When the 
tumour is in contact with a bone, the periosteum is in some 
cases destroyed, and the bone, thus deprived of its fibrous en- 
velope, becomes carious ; in other cases again, the periosteum 
is remarkably thickened, and occasionally it secretes an osseous 
substance which surrounds the tumour and forms an envelope 
to it. 

In general, the irritation which is created in the parts around 
the sac sooner or later attacks the sac itself, and not unfrequent- 
ly terminates in its perforation. A haemorrhage then ensues, 
which in some cases only ceases with the life of the individual, 
and in others, is arrested either by the natural conformation 
of the part, as when the blood flows into the pericardium, or by 
some accidental circumstance, as when the adhesions which 
had been formed round the sac form a second envelope, which 
prevents the haemorrhage proceeding any farther. The per- 
foration of the sac is not necessarily followed in every case by 
haemorrhage, for it often happens that some organ in contact 
with the sac supplies the place of that portion of its parietes 
which had been destroyed, and thus prevents the escape of its 
contents. 

All aneurisms do not necessarily terminate in the manner de- 
scribed in the last paragraph; on the contrary, a spontaneous 
cure is sometimes effected by one of the processes described in 
the four cases following. 

Case. I. — The coagulum is spontaneously absorbed, the sac 
gradually contracts, and there remains only a small tumour, 
which may even eventually disappear altogether. 

Case II. — The sac may exert such a degree of pressure on 
that part of the artery immediately above it, as to cause its ob- 
literation, in consequence of which the sac disappears, as in 
those cases where the surgeon produces the obliteration of the 
artery by applying a ligature round it. 



236 DISEASES OF THE ARTERIES. 

Case III.— The parietes of the sac may be destroyed by 
gangrene, and the artery subsequently become obliterated. 

Case IV. — Several instances have been recorded of abscesses 
in the neighbourhood of the sac giving rise to an adhesive in- 
flammation in the interior of the artery, the consequence of 
which was, as in the preceding cases, the obliteration of the 
artery and cure of the aneurism. 

In the species of aneurism last described (the false aneurism 
of authors) the inner and middle coats are first ruptured, and 
the bursting of the outer coat follows, if at all, at some subse- 
quent period. But there is yet another case, in which all three 
coats give way together; the artery is thus suddenly perforat- 
ed, and no sac is formed. I saw a case of this description in 
a patient affected with peritonitis, who died almost suddenly 
in a fit of syncope. On dissection, an enormous effusion of 
blood was found in the abdomen. One of the iliac arteries 
presented an aperture nearly as large as a six-pence, which 
seemed as if the piece were cut out. In another case of sud- 
den death, I found a similar perforation in the splenic artery ; 
it has likewise been observed in the hepatic artery. In all 
these cases, the artery was perforated as if it had been wound- 
ed by a sharp instrument, and with the same results. We are 
not, however, to suppose that all wounds of arteries from ex- 
ternal injuries are followed by such fatal consequences. The 
following is a brief summary of the different cases in which a 
spontaneous cure may be effected. 

Case I. — When the wound is simply a punctured one, made 
by a small instrument, a coagulum forms in it, which though at 
first it acts merely as a mechanical stopper, subsequently be- 
comes organized, and is transformed into a tissue in every 
respect similar to the arterial. 

Case II. — When the incision of the artery is parallel to its 
axis. The same phenomena are observed as in the preceding 
case. 

Case III. — When the incision of the artery is made trans- 
versely to its axis. In this case very different phenomena re- 
sult according as the cellular sheath has been removed or not. 
When it has been removed, as is sometimes done in experi- 



DISEASES OF THE ARTERIES. 237 

ments on animals, the haemorrhage only ceases with the life of 
the animal. On the other hand, when the artery has not been 
denuded of its cellular coat, it arrests the blood in its meshes, 
and thus favours the formation of a coagulum ; the haemorr- 
hage ceases, and the coagulum in some instances becomes or- 
ganized, and is transformed into ft'true arterial tissue ; more 
commonly, however, the coagulum does not become organ- 
ized, but at the end of a certain time is detached, and a fresh 
haemorrhage ensues. 

Case IV — When the artery is perfectly divided, if the cel- 
lular sheath has been dissected away, the haemorrhage which 
ensues is necessarily mortal ; but if the sheath has not been re- 
moved, the internal and middle coats retract, so as to leave the 
cellular coat projecting several lines beyond them ; and the 
meshes of this cellular coat serving to entangle the blood, a 
coagulum is thus formed, which extends along the interior of 
the artery as far as the next collateral branch, and eventually 
that portion of the vessel is converted into an impermeable 
cord. 

The last variety of perforation which remains for us to con- 
sider is, where the solution of continuity, instead of passing si- 
multaneously through all the coats, or passing in succession from 
the inner to the middle, and from the middle to the outer coat, 
takes an opposite route and proceeds from without inwards, 
until it reaches the inner membrane, which (it is stated by 
authors) not unfrequently forms a hernia through the outer 
tunics. 



II. Narrowing of the Arteries. 



This alteration may be either congenital or the effect of 
disease. The aorta may be smaller than natural throughout 
its whole extent, or the contraction may be confined to a cer- 
tain portion. Contraction of the abdominal aorta is more fre- 
quent than that of the thoracic portion ; and in some cases the 
contraction of the former part co-exists with the dilatation of 



238 DISEASES OF THE ARTERIES. 

the latter. Congenital contraction of the aorta is generally- 
united with extreme thinness of its parietes. In some cases, 
the caliber of the abdominal aorta is so diminished as hardly 
to equal that of the external iliac artery. 

The aorta has sometimes been found contracted in one point, 
and retaining its natural caliber both above and below the 
point thus constricted. A remarkable case of this description 
is recorded in the 2d vol. of the Journal de Desault. Whilst 
injecting the body of a woman fifty years of age, he found the 
aorta, immediately below where it gives off the left subclavian, 
reduced to the diameter of a goose-quill. From its origin at 
the heart to the commencement of its arch it presented its nat- 
ural dimensions ; the arch itself was slightly dilated, and the 
arteries which arose from it were nearly twice as large as 
usual, and effectually kept up a collateral circulation. The 
membranes at the contracted part were not thicker than 
natural. 

Another case of partial contraction of the aorta nearly sim- 
ilar to the preceding is minutely described by M. Reynaud in 
the first vol. of the Journal Hebdomadaire de Medecine. 

In such cases as these, where there is no appearance of 
previous disease, it is difficult to decide whether the contrac- 
tion be congenital or accidental ; the difficulty, however, van- 
ishes when the coats are found thickened, or when the capacity 
of the artery is diminished by the presence of ossifications, or 
other morbid productions. The contraction produced in this 
way is sometimes so considerable as to reduce the caliber of 
the aorta to that of the femoral artery. I recollect seeing a 
case in which one of the external iliacs was almost completely 
transformed into an osseous canal ; and its capacity so dimin- 
ished as with difficulty to admit the introduction of a moderate 
size probe. 



DISEASES OF THE ARTERIES. 239 



III. Obliteration of the Arteries. 



It is not very uncommon to find arteries of the second or 
third order obliterated, and in some cases the aorta itself has 
been found impermeable. 

The obliteration of an artery may be effected in various 
ways ; thus, in some cases we find only a ligamentous cord, 
such as is formed in the adult by the umbilical artery ; in others 
the point where the artery is obliterated is occupied by coag- 
ula of fibrine, more or less organized, adhering firmly to the 
parietes of the vessel, and sometimes incorporated with them ; 
whilst in other cases again, the obliteration results from the 
complete obstruction of the cavity of the artery by osseous con- 
cretions. 

The first species of obliteration has been observed twice in 
the aorta ; once,* in a boy fourteen years old, in whom the 
aorta was completely obliterated near its junction with the 
ductus arteriosus, and a second timef in a boy of the same 
age, whose aorta was obliterated for five or six lines imme- 
diately below the origin of the left subclavian. In both these 
individuals there were present all the symptoms of organic 
disease of the heart, and in both the circulation was kept up 
by the aid of collateral arteries considerably dilated. There 
was this difference, however, that in the first case the ductus 
arteriosus was converted as usual into a ligamentous cord, 
whilst in the second it was permeable and even considerably 
dilated. 

The second species of obliteration has been more frequently 
observed than the first, but no instance of it has as yet been 
seen in the aorta. It has been repeatedly found in the arteries 
of the lower extremities coinciding with the disease known 



* Sir A. Cooper On the Ligature of the Aorta. 
t Journal de Corvisart, fyc. torn, xxxiii. 



240 DISEASES OF THE ARTERIES. 

by the name of gangrcena senilis, and it is reasonable to con- 
clude that in these cases the obliteration of the arteries is the 
cause of the gangrene : this much at least is certain, that it is 
not the effect, for in a patient who died of gangrene of one 
foot, and in whom all the arteries of that limb were complete- 
ly obstructed by solid coagula of fibrine, the commencement 
of a similar obstruction was found in the arteries of the oppo- 
site limb, although not a sign of gangrene was observable in it. 
It appears to me highly probable that if this individual had 
lived for some time longer, the arteries of the sound limb 
would have become more and more obstructed, and that the 
foot of that side would have then become gangrenous also. 

An example of the third species of obliteration has been pub- 
lished by Dr. Goodisson of Dublin. Near the origin of the 
inferior mesenteric, a hard tumour was felt in the aorta, which, 
on dissection was found to consist of a dense fibrinous concre- 
tion, compared by the author to the structure of the gizzard in 
birds ; this tumour completely blocked up the narrow passage 
which was left by an osseous substance that projected inwards 
from the parietes, which were themselves extensively ossified. 
The common iliac artery and a portion of the external iliac of 
the left side were completely obliterated, as was also the com- 
mencement of the right common iliac. Notwithstanding all 
these obliterations, the circulation was kept up by collateral 
branches, and the lower extremities were not in the least 
wasted. 

Beclard was of opinion that the obliteration of the arteries 
by the ossification of their parietes might be one of the causes 
of gangrcena senilis. 



DISEASES OF THE ARTERIES. 241 



CHAPTER III. 



CONGENITAL LESIONS OF NUTRITION. 



I shall not at present enter into a detailed account of the 
several varietes which the arteries may present in their form 
and distribution, but shall content myself with enumerating 
those which materially influence the course of the blood, and 
have consequently most importance in a medical point of view. 

Two aortas sometimes arise from the left ventricle, or, as 
more frequently happens, the aorta is single at its origin, but 
divides into two, almost immediately on its leaving the heart. 
Of the two trunks thus formed, one terminates on the innomi- 
nata, the other, after giving off the left carotid and subclavian, 
goes to form the descending aorta. 

The aorta may arise from both ventricles together ; this mal- 
formation is most frequently seen in one of the following cases ; 
1. when the septum of the ventricles is wanting ; 2. when it 
deviates from its natural situation ; and, 3. when there exists an 
accidental passage from the right ventricle into the aorta. 

Lastly, the aorta sometimes arises from the right ventricle, 
and it is very remarkable that the walls of that ventricle are al- 
ways much thicker in such cases. 

The aorta is liable to some varieties of structure at its origin : 
in some cases it has only two valves, which are then very large ; 
in others, it has four, or even five valves. 

The pulmonary artery presents as many varieties in its ori- 
gin as the aorta. Sometimes it arises from the left ventricle, 
and sometimes it is given off by the aorta, or even by the sub- 
clavian artery. In other cases, its natural orifice has been 
found obliterated, but then the ductus arteriosus and foramen 
ovale both remained pervious. The last variety I shall enu- 
merate is where there is no trace of any pulmonary artery, and 

Vol. II. 32 



242 DISEASES OF THE ARTERIES. 

the lungs receive all their blood from the bronchial arteries 
furnished by the aorta. 

The pulmonary artery may be regular at its origin and 
anomalous in its course and distribution. Thus, it has been 
found in foetuses passing directly to the lungs, without at all 
communicating with the ductus arteriosus, which arose dis- 
tinctly from the right ventricle. In other instances, it has been 
known to give off the aorta descendens. 

Tiedemann's beautiful plates give an admirable representa- 
tion of the different varieties in the origin of the arteries which 
usually arise from the arch of the aorta ; and the reader will 
find all the information he can desire on this subject in Meckel's 
Manual of Anatomy. 



CHAPTER IV. 



LESIONS OF SECRETION. 



When we excite an artificial irritation in the artery of an 
animal by compressing it strongly, or by introducing into it a 
solid substance or irritating fluid, (taking care in the latter case 
to confine it by ligatures,) its parietes soon present a variety of 
morbid alterations.* They become injected, swollen, and 
softened, and at the same time are infiltrated by a clear serous 
fluid ; their internal surface is coated by a layer of a plastic sub- 
stance, and collections of pus form either between the coats, 
or in the interior of the vessel. If the artery continues full of 
blood during the experiment, that fluid coagulates, and is al- 
tered in a variety of ways by its mixture with the fluids which ' 
the internal membrane exhales. 

These different appearances have likewise been observed in 
the human subject. M. Bouillaud found the internal surface of 



1 Gendrin, Histoire Jlnatomiqut des Inflammations, 



DISEASES OF THE ARTERIES. 243 

the aorta lined by a perfect false membrane, and when the 
membrane was removed the subjacent surface presented a 
bright red colour. I once found the inner membrane of the 
aorta raised by five or six small abscesses, each about the size 
of a nut, and situated between the internal and middle coats: 
the pus contained in these abscesses had the usual appearance 
of phlegmonous pus; there was no sign of redness in any of 
the coats. Pus is likewise occasionally met with in the interior 
of the arteries, where it is usually mixed with the blood, the 
appearance of which it materially alters ; it is also found with- 
out any admixture of blood. In an individual in whom several 
of the pulmonary lobules appeared in a state of purulent infil- 
tration, I " ascertained satisfactorily that the appearance was 
produced by a number of the minute branches of the pulmon- 
ary artery being filled with pus. 

There is another morbid secretion which is still more fre- 
quently found than pus under the internal coat of arteries; I 
allude to that peculiar substance which has long been described 
under the name of atheromatous matter. It has the consistence 
of suet, feels greasy to the touch, and when broken down under 
the finger gives the sensation of minute gritty points thinly 
scattered through a fatty substance. In other cases the saline 
matter is more abundant, and exceeds in quantity the fatty 
substance, or is even found without any of that substance, in 
which case it forms one or more hard concretions that have a 
much stronger resemblance to mortar than to bone. These 
concretions present considerable variety in their physical prop- 
erties, and, as they constitute one of the most frequent altera- 
tions to which the arteries are liable, I shall enter somewhat 
minutely into the history of their developement. 

Calcareous concretions are so constantly found in the arteries 
at an advanced period of life, that Bichat computed that out of 
ten persons over sixty years of age, seven would be found with 
these concretions. According to Baillie, it is more common 
to find the arteries ossified than not, in old age.* Neither are 



* There are, however, some individuals who arrive at an extreme old age with- 
out their arteries becoming ossified, as I have myself ascertained by dissection. 



244 DISEASES OF THE ARTERIES. 

the other periods of life exempt from this affection: thus, 
Young found the temporal artery ossified in an infant of fifteen 
months, and Doctor Wilson saw the aorta ossified at the age 
of three years. I myself observed several ossiform plates in 
the aorta of a little girl only eight years old, and I have seen 
five or six instances of similar appearances in persons of from 
eighteen to twenty-four years of age; lastly, I found an exten- 
sive ossification of the superior mesenteric in an individual not 
quite thirty. 

I do not know of any instance of the internal membrane 
having been the seat of these calcareous concretions ; but it is 
often detached from its connexions by them. We have already 
seen that the middle or fibrous coat sometimes undergoes a 
true osseous transformation, but that case should not be con- 
founded with this which we are at present considering, where 
the bony matter is simply deposited between the internal and 
middle coats. The matter thus deposited originates either in 
the atheromatous matter already described, which it some- 
times seems to take the place of, just as calcareous concretions 
in the lungs take the place of tubercles ; or in those white 
patches, the nature of which is as yet unknown, but which are 
apparently formed by a deposition of albuminous matter be- 
tween the inner and middle coats ; or, lastly, in cartilaginous 
patches, which seem only a more advanced stage of the pre- 
ceding. 

At the same time that these calcareous depositions are form- 
ing, the middle or fibrous coat undergoes the same alterations 
as occur in every tissue where a process of morbid secretion is 
going forward. In some cases it becomes hypertrophied, and 
so contributes in part to the considerable thickening which the 
parietes of the artery in such cases not unfrequently present ; 
in others it becomes atrophied, and the place which it occupied 
is taken up by the newly formed calcareous concretion. This 
latter case, namely the deposition of bony matter accompanied 
by atrophy of an adjacent membrane, has in this, as in other 
instances, been often mistaken for the transformation of that 
membrane into bone. 



DISEASES OF THE ARTERIES. 245 

The appearance of these ossiform concretions is exceedingly- 
variable. Sometimes they appear in the form of minute grains 
scattered over the internal surface of the vessel, and sometimes 
they form irregular plates of various extents and depths : in 
some cases, the artery is so incrusted with them, as to be con- 
verted into an inflexible tube ; in other cases again, the artery, 
when pressed under the finger, gives the sensation of contain- 
ing a number of small hard bodies playing on each other, and 
as if jointed together. 

These concretions may not alter in the least the internal 
form and dimensions of the vessel, or they may project so con- 
siderably as almost to obliterate its cavity. Beclard was of 
opinion that they might in this way produce gangraena senilis. 
Another hypothesis, which, though not proved, may yet turn 
out to be correct, is, that they may be detached from their con- 
nexions and fall into the cavity of the artery, from whence they 
may be carried in the blood into arteries of smaller caliber, 
and effectually plug them up. 

It has been proved by chemical analysis that these concre- 
tions are composed of phosphate of lime united with a certain 
proportion of animal matter. The following proportions have 
been assigned by Brande : 

Phosphate of Lime, ... 65.5 

Animal Matter, - - - 34.5 

100.0 

If we compare the different arteries with regard to the fre- 
quency of their ossification, we shall find that the aorta is the 
most liable of any to this alteration. Every one of the branches 
which arise from it have likewise been found ossified. Thus, 
the coronary arteries are frequently so, not only in their trunks, 
but also in their subdivisions. The ossification of these arte- 
ries has been assigned as the cause of angina pectoris, of 
atrophy of the heart, and of certain cases of asthma and of 
sudden death. This hypothesis, for so I must call it, has not 
been confirmed by experience. The large vessels which arise 
from the arch of the aorta not unfrequently present at their ori- 



246 DISEASES OF THE ARTERIES. 

gin a sort of bony ridge which projects into their interior, and 
is perhaps one of the reasons which causes the difference of 
the poise in the right and left arm so often felt in old men. It 
is also very common to find in old people the cerebral arteries 
studded with cartilaginous and osseous plates. M. Bouillaud 
has lately shewn, in ah interesting essay, the connexion which 
exists in several cases between cerebral haemorrhage and the 
ossification of the arteries which are distributed to the brain. 
The different branches given off by the abdominal aorta have 
not all the same tendency to ossification ; thus, it is exceeding- 
ly common in the splenic, while it is equally rare in the hepatic 
and the coronary artery of the stomach. At the origin of the 
common iliacs, there is often a bony ridge similar to that which 
we have already noticed as not unfrequently obstructing the ca- 
rotid and subclavian arteries at their origins. The only instance 
I am acquainted with of the principal branches of the hypogas- 
tric artery being ossified is that recorded by Haller {Opuse. 
Patholog. Obs. 59.) The arteries of the lower extremities are not 
unfrequently the seat of these calcareous depositions : every 
physician who has been in the habit of feeling the pulse of old 
persons, must have repeatedly observed the ossification of the 
radial artery. 

The greater number of the morbid secretions we have enu- 
merated have likewise been found in the pulmonary artery, 
but much more rarely than in the aorta and its branches. I 
have occasionally seen the internal surface of the pulmonary 
artery studded with a number of white patches, slightly eleva- 
ted. In one instance I found two or three smajl plates of car- 
tilage, and in another, a small plate of bone that caused a slight 
elevation of the internal membrane ; it was situated near the 
bifurcation of the vessel. Ossification of the pulmonary artery 
is, then, a rare occurrence, but not an impossibility, as Bichat 
pronounced it to be. 

Ossification of the arteries, like most other alterations of nu- 
trition and secretion, cannot be explained by an increase or 
diminution of the sum of vitality distributed to the part affect- 
ed, or, in other words, by any variety or degree of atony or of 
local irritation or inflammation. I have already argued this 



DISEASES OP THE ARTERIES. 247 

point so fully in the first volume, that it is unnecessary for me 
to repeat the arguments here. Suffice it to say, that all we 
know of the formation of these ossifications is, that they are the 
result of a derangement in the natural process of secretion and 
nutrition. This, however, is only the first step in our inquiry. 
We should next endeavour to ascertain what are the causes of 
that derangement, and when we have discovered them, we may 
then consider the best means of counteracting and combating 
them. On this subject, I shall venture to offer an hypothesis. 
Medical practitioners have long remarked the co-existence or 
succession of three principal phenomena in persons affected 
with gout ; namely, hard concretions in the joints, depositions 
of calcareous matter in the arteries, and gravel in the urinary 
passages. They have likewise observed, that gouty subjects, as 
well as those afflicted with gravel, are generally persons who 
have committed excesses at table, and made too free a use of 
animal diet. Moreover, within these few years, M. Magendie 
has shewn, that by feeding a carnivorous animal on substances 
that contain little or no azote, his urine may be deprived of the 
uric acid, and of the phosphate of lime ; whence it follows, that 
if an individual makes an excessive use of substances contain- 
ing much azote, his urine will necessarily have to eliminate 
from the blood a proportionably great quantity of uric acid and 
phosphate of lime. But if the quantity of these salts becomes 
so great that they cannot all be carried off by the urine, we may 
suppose that other ways of elimination may then be opened ; 
that the uric acid which is found in gouty joints may be that 
superabundant portion of it which the kidneys were unable to 
eliminate ; and that the phosphate of lime deposited in the ar- 
teries may likewise be that portion which could not pass off 
from the blood with the urine. By this hypothesis several phe- 
nomena are connected together, which at first sight, appeared 
to bear no relation to each other. There is phosphate of lime 
deposited in the arteries, and uric acid in the joints, at the same 
time, and for the same reason, namely, because there is an ex- 
cessive formation of each in the blood. Before these local af- 
fections made their appearance, the blood had already under- 
gone an alteration, and in consequence a general process of se- 



248 DISEASES OF THE ARTERIES. 

cretion was requisite to rid it of its superfluous ingredients. 
This tendency to establish a process of secretion, is always ac- 
companied by an increased afflux of blood towards the seat of 
the secretion, and by an exaltation of its vitality ; and in this 
way is produced the local irritation which, in a greater or less 
degree, precedes all morbid secretions. If this reasoning be 
admitted, it follows of course, that the irritation is itself only an 
effect, and so far from being regarded as the cause of the morbid 
secretions that are formed, should be considered as merely ex- 
isting for the purpose of favouring the elimination of a morbid 
matter from the blood. When I reflect on the conclusion to 
which this argument has led me, I really feel surprised at thus 
finding myself involved in the antiquated doctrines of the hu- 
moral pathology. But, why should I on that account reject an 
hypothesis which appears so satisfactorily to connect all the 
facts that have been observed ; which embraces them all, 
symptoms, morbid appearances, and method of treatment ; and 
which, I have no hesitation in affirming, gives a more satisfac- 
tory and more scientific explanation of these facts, than the hy- 
pothesis in vogue at the present day, which considers each of 
these alterations as the effect of an irritation purely local, and 
independent of any general or constitutional derangement. 



CHAPTER V. 



LESIONS OF THE INNERVATION OF THE ARTERIES. 



The arteries are, throughout the greater part of their subdi- 
visions, surrounded with a net-work of nerves that are furnish- 
ed by the great sympathetic, and appear to penetrate their 
coats. They probably receive some influence from these nerves 
in the state of health ; and it is reasonable to suppose that, like 



DISEASES OP THE ARTERIES. 249 

all other parts to which nerves are distributed, they are some- 
times diseased in consequence of a primitive modification of the 
nervous influence to which they are subjected. This supposi- 
tion is, however, as yet unsupported by facts ; and it is possible 
that the plexuses of nerves which surround the arteries, may 
not be destined for the use of the arteries themselves, but only 
accompany them to their ultimate destination, in the capillary 
system. 

Laennec admitted the existence of neuralgia of the arteries, 
and laid down as the symptoms by which this affection was 
characterised, acute pain along the course of the arteries, and 
an increase in their pulsations with or without bruit de soufflet. 
He accounted for the violent pulsations and the peculiar sound 
by a spasm of the arterial parietes. Whether we admit the 
existence of spasmodic action in the arteries or not, certain it 
is, that violent pulsations are sometimes felt along the course 
of the arteries, more especially of the superior portion of the 
abdominal aorta, which continue from a few hours to several 
days, and often recur at longer or shorter intervals. Morbid 
anatomy has not as yet offered any explanation of these pulsa- 
tions ; by some authors they have been attributed to irritation 
and hyperemia of the artery (arteritis), but this explanation is 
as much an hypothesis as the spasm of Laennec. 

A loud bruit de soufflet accompanying the dilatation of the 
vessel is often heard in all the principal arteries; in this case, 
too, morbid anatomy has not as yet discovered any physical 
alteration, either in the parietes of the arteries, in the heart, or 
in the blood itself, which can account for the production of this 
peculiar sound. It has most frequently been observed in in- 
dividuals affected with hypertrophy of the heart ; but I have 
myself heard it in persons whose heart presented not the slight- 
est symptom of disease, either in the thickness of its parietes 
or in the capacity of its cavities. 

There are, therefore, still many curious and interesting re- 
searches to make respecting the cause of these phenomena. 
Our present ignorance on the subject is one of the thousand 
proofs we have of the insufficiency of our morbid anatomy to 
account for all the phenomena of disease. 
Vol. II. 33 



250 DISEASES OP THE VEIHR- 



SECTION IIL 



DISEASES OF THE VEINS. 



For a long period no other disease of the veins was known 
than that usually designated by the name of varix ; and even 
in this affection the nature of the pathological change was fre- 
quently mistaken. Towards the end of the last century the 
celebrated Hunter found the veins in horses red, thickened, 
and filled with pus; from that time, the attention of patholo- 
gists has been directed to the affections of these vessels, and at 
the present day all anatomists are agreed that the veins are 
liable to the same diseases as the other parts of the body. 

M. Cruveilhier has recently instituted a set of ingenious ex- 
periments on those vessels, which have led him to the conclu- 
sion that, whenever a part of the body is so irritated as to ex- 
hibit the usual phenomena of inflammation, the venous tissue 
is the principal seat of these phenomena. 

Diseases of the veins resemble the diseases of arteries in 
some respects, and differ from them in others. The veins 
never exhibit the morbid alteration termed aneurism, because 
their coats all yield equally to any pressure to which they are 
submitted ; whereas in the arteries it is only the external coat 
which is susceptible of thus yielding : besides, the veins are 
not exposed to the same constant shock from the columns of 
blood that the arteries are ; but even though a vein were ex- 
posed to this same shock, the consequence would be, not a 
rupture of any of the coats, but a dilatation of them all. 
Whence is it that calcareous concretions are so rarely met 



DISEASES OF THE VEINS. 251 

"with in the veins, while they are so common in the arteries ? I 
do not think that this difference can be accounted for solely by 
their difference of texture ; for the texture of the pulmonary 
artery is the same as that of the aorta, and the right side of the 
heart is organized precisely as the left ; and yet ossifications 
are incomparably more frequent in the aorta and left side of 
the heart than in the pulmonary artery and right side. The 
reason why the blood is more frequently coagulated and or- 
ganized in the veins than in the arteries, Is probably to be found 
in the difference of the circulation in these two orders of ves- 
sels. Lastly, pus is more frequently found in the veins than 
in the arteries ; which I think may be satisfactorily accounted 
for by the difference in the functions of these vessels : the pus 
which is found in the arteries may, in the great majority of 
cases, be considered as having been formed there ; whereas 
pus found in the veins, though in some instances it may be se- 
creted there, is much more frequently brought thither by ab- 
sorption. 



CHAPTER I. 



LESIONS OF CIRCULATION. 



Thb veins, like the arteries, present two different kinds of 
redness ; one the effect of active hyperaemia, the other pro- 
duced after death by the imbibition of the blood. The latter 
species, which is much the most common, presents the same 
uniform aspect as in the arteries, but the shade of colour is 
different, owing to the different nature of the blood contained. 

The redness of the veins from imbibition of the blood is more 
common than that of the arteries from the same cause ; which 
appears to depend on the circumstance of its occurring at an 



252 DISEASES OP THE VEINS. 

earlier period after death. If we examine the aorta and the 
inferior cava in the same subjects, we shall find the latter vessel 
quite red in several cases where the aorta does not present the 
slightest alteration of colour. The redness of the veins differs 
also from that of the arteries in this, that it pervades all the 
coats of the vein, whereas in the arteries it is generally con- 
fined to the inner coat. 

It may be laid down as a general principle that, in the veins 
still more than in the arteries, the existence of redness unac- 
companied by other morbid changes cannot be considered as 
a proof of disease. M. Gendrin repeated on the veins of living 
animals the same experiments, and with the same results, as 
on the arteries. These have been already described in the 
preceding section. 



CHAPTER II. 



LESIONS OP NUTRITION. 



The internal membrane of the veins is sometimes consider- 
ably softer than natural, and may be readily broken up into a 
soft pulpy mass by scraping it with a scalpel. Whenever a 
vein appears red in its inner surface, we should examine the 
consistence of its inner membrane before we decide as to the 
nature of the redness. 

The same membrane is also in some cases much thicker 
than natural ; this thickening may be uniform, or may be con- 
fined to one or more points ; in the latter case, the inner surface 
of the vessel has a rough uneven appearance. 

At the same time that the internal membrane presents either 
of these alterations, it may retain its natural pale appearance, 
or may present different uiades of colour. 



DISEASES OF THE VEINS. 253 

The valves of veins, being formed by the folds of the inner 
membrane, are liable to the same alterations as the membrane 
itself. I have seen them so much thickened that their natural 
transparency was lost ; while, in other instances, they were 
partially destroyed, and resembled so many fringes floating 
loose in the cavity of the vessel, or irregular bands passing 
across it. When the valves are altered in either of these ways, 
we generally find a certain portion of coagulated blood adher- 
ing to them. 

The middle membrane also is liable to become softened. 
When this alteration occurs, the vein may be torn by the slight- 
est effort ; and even during the life of the individual, any exer- 
tion which causes an accumulation of blood in the veins may 
produce their spontaneous rupture. 

The middle membrane is likewise subject to atrophy, and 
then the parietes of the vein acquire an extraordinary degree 
of tenuity. 

Lastly, this membrane is liable to be hypertrophied, and in 
this way are produced a variety of appearances in the parietes 
of the vein, according to the situation of the hypertrophy, and 
the degree to which it arrives. One of the first effects of hy- 
pertrophy of the middle membrane is to render it distinctly vis- 
ible in a number of veins where it naturally exists in such a 
rudimentary state as to be imperceptible. In those places 
where it usually is visible, the longitudinal fibres are rendered 
much more distinct, and, as the hypertrophy increases, the 
membrane assumes quite another appearance ; it loses its 
transparency, acquires a yellowish colour, and presents a cer- 
tain degree of elasticity, so that when the vein is cut across, 
its orifice remains open as that of an artery would do. Indeed 
the outer appearance of a vein in this state of hypertrophy pre- 
sents a striking resemblance to that of an artery ; but if we dis- 
sect its middle membrane, we find this remarkable difference 
between it and the middle coat of arteries, that the former 
never presents any trace of circular fibres, nor does it eveag 
possess the same degree of elasticity as is observed in the true 5 
arterial coat. 



254 DISEASES OF THE VEINS. 

Can the middle coat of veins be ever so hypertrophied as to 
present the appearance of muscular tissue ? I think I once de- 
tected the existence of muscular fibres in the parietes of the in- 
ferior cava, ■ not far from its termination in the heart ; the 
parietes of the vessel were in an extreme degree of hypertro- 
phy, and the appearance of muscular tissue struck me at the 
time as being very well marked ; however, I should like to re- 
peat the observation before I positively announce the fact, 
which is the more interesting to ascertain, as it would be an 
example of the same formation being produced in man by a 
morbid change which is in other animals the natural condition 
of the part. In the horse, for instance, the structure of the 
vena cava, near its entry into the right auricle, appears evident- 
ly muscular, and seems in fact a prolongation of the auricle. 

True hypertrophy of the middle coat may be confounded 
with another case in which the thickening of the membrane is 
only apparent, and is produced by a quantity of blood accumu- 
lating in its tissue. The parietes of the vein in this affection 
resemble a portion of cellular tissue in a state of phlegmon not 
yet advanced to suppuration, and in other cases, a dense co- 
agulum: the colouring matter of the blood is subsequently 
absorbed, and there remains behind only the white fibrine in a 
solid form, and combined molecule to molecule with the coats 
of the vein, which then present the lardaceous appearance 
described by authors as a peculiar tissue, though in reality it is 
nothing more than a deposition of blood from which the colour- 
intf matter has been absorbed, and the fibrine become incor- 
porated with the tissue of the part. The different stages of 
this process may be easily traced. 

The alterations of nutrition in the external membrane of 
veins, are the same as in the external membrane of arteries, 
which have been already described. 

The several membranes of which the parietes of the veins 
are composed are liable to ulceration and perforation. It is 
more common to find the veins perforated than simply ulcer- 
ated ; indeed, there are few of the principal veins in which 
perforation has not been observed. It has been seen, 1. in the 
superior cava both within and without the pericardium; % in 



DISEASES OF THE VEINS. 255 

the inferior vena cava ; 3. in the vena porta?, both within and 
without the liver; 4. in the splenic vein; 5. in the jugular vein; 
6. in the subclavian; 7. in the veins of the extremities; and, 8. 
in the veins that run between the coats of the intestines. 

In some cases, perforation of the vein takes place without its 
coats exhibiting any appearance of disease in the vicinity of the 
perforation ; in such cases, the rupture either occurs sponta- 
neously, or is caused by some external violence. I remember 
the case of a man, who, whilst engaged in a violent struggle, 
fell senseless to the ground, and expired in a few seconds: on 
dissection, it was discovered that there was a perforation of the 
abdominal vena cava ; the borders of the perforation seemed as 
if they had been torn asunder, and the coats of the vein in the 
neighbourhood were perfectly healthy. 

In other cases, the vein which is the seat of perforation pre- 
sents different morbid alterations, such as ulceration, softening, 
atrophy, &c. 

Lastly, there are some cases in which the perforated vein is 
situated in the midst of diseased parts ; the affection of the vein 
is then only secondary, and its solution of continuity proceeds 
from without inwards. In this way, veins have been repeatedly 
found perforated at the bottom of carcinomatous ulcers of the 
stomach. 

The several alterations of nutrition that have been enumera- 
ted may alter to a greater or less extent the caliber of the af- 
fected- veins. 

The term varicose has long been applied to the veins in a 
state of dilatation : the following are the principal species of this 
affection : — 

1st Species. — Simple dilatation unattended by any other al- 
teration, either affecting the whole length of the vein, or existing 
only at intervals. 

This first species of varix often co-exists with the chronic 
hyperaemia of an organ, and sometimes persists after the hy- 
peremia has totally disappeared ; in other cases it is unconected 
with any affection of, the capillaries. 

2nd Species. — Dilatation of the veins, either uniform or at 
intervals, with thinning of the parietes at the dilated points. 



256 DISEASES OP THE VEINS. 

3rd Species — Uniform dilatation of the veins with increased 
thickness of the parietes. 

Ath Species. — Dilatation of the veins at intervals, with thick- 
ening of the parietes at the points where the dilatations exist. 

In these two latter species, the vessel increases in length as 
well as in breadth, and in consequence becomes quite tortous 
in its course. 

5th Species. — Dilatation of the veins, with the developement 
of septa or partitions which divide the interior of the vessel 
into small compartments that allow the blood to stagnate and 
coagulate. When this alteration takes place only at intervals, 
it may readily be mistaken for a congeries of small tumours 
composed of a spongy tissue, into which the vein discharges its 
contents; but on examination it will be found that these tumoUrs 
are formed by the vein itself, which is dilated, and its interior 
divided into cells. 

6th Species. — Dilatation of the vein, its interior divided into 
a number of separate compartments, as in the preceding 
species, and in addition, its parietes drilled by a number of 
minute holes, which allow the blood to pass from the vein into 
the surrounding cellular tissue. This morbid alteration of the 
venous structure is precisely analogous to the natural perforated 
condition of the splenic vein within the spleen. The tumours 
described by authors under the name of erectile tumours, are 
in reality nothing more than a cluster of small veins communi- 
cating with each other and with the surrounding cellular tissue 
by the holes with which their parietes are drilled in the manner 
just described. The cellular tissue, situated between the veins 
thus affected, is liable to various alterations of nutrition and 
secretion, whence arise the vast variety of appearances which 
these tumours present, the numerous morbid productions that 
are found in them, the different degenerations which they are 
said to undergo, their transformation into cancer, &c. &c. 

The structure of every variety of haemorrhoidal tumour may 
be referred to one or other of the six species of varix just 
enumerated; but these alterations are not solely confined to 
the veins in the neighbourhood of the anus : I once found the 
external jugular altered in the manner described in our sixth 



DISEASES OF THE VEINS. 257 

species. The tumours formed by dilated veins sometimes dis- 
appear spontaneously; in such cases, the veins are generally 
found on dissection completely obliterated. 

Amongst these different species of varix, there are some 
which evidently depend on an increased activity in the nutri- 
tive process ; others again depend on a diminution in the ac- 
tivity of that process, whilst others are simply the mechanical 
result of pressure exercised on some principal vein ; in this 
case the small veins which pour their contents into the venous 
trunk on which the pressure is exercised become greatly dilat- 
ed and elongated, and their parietes are often considerably hy- 
pertrophied. 

Contraction and obliteration of the venous cavities are much 
more uncommon than their dilatation. They may be produc- 
ed, 1. by causes existing outside the veins, such as tumours 
which mechanically compress them; 2. by causes seated in 
their parietes; or, 3. by causes that exist in their interior. 
Amongst these, the coagulation of the blood must be included : 
indeed, it is now universally admitted that the blood may coag- 
ulate within the veins during the lifetime of the individual. 
What the circumstances are which influence its coagulation, it 
is not so easy to determine : in some cases, it appears to depend 
on the state of the blood itself; in others, on the state of the 
venous parietes, as when they cease to exert their usual in- 
fluence on the course of the blood, or when their interior sur- 
face is rugged and uneven, or, lastly, when they secrete pus 
and other matters which are known to promote the coagula- 
tion of the blood. 

Whatever be the circumstances under which the coagulum 
is formed, it may either still allow the blood to pass through in 
a smaller stream, or may block up the passage altogether. 
These coagula present considerable variety in the firmness of 
their adhesion to the parietes of the vein, in their physical 
characters, (colour, density, &c.) and in their organization. 
They live precisely as the veins in which they are formed, and, 
like every other part endowed with life, keep up a constant 
process of nutrition and secretion, and are also liable to become 
diseased. 

Vol. II. 34 



258 DISEASES OF THE VEINS. 

The obliteration of the veins may be still more complete than 
in the preceding case; and instead of their cavities being plug- 
ged up with coagula, it sometimes happens that no vestige re- 
mains of any cavity, and the vein becomes a fibro-cellular cord. 

Obliteration of the veins often gives rise to the establishment 
of a collateral circulation, which may be kept up either by a 
number of small veins, or by one principal vessel that acquires 
an unusual developement. 

M. Reynaud has published a case* in which the left iliac 
vein was completely obliterated from above the origin of the 
internal hypogastric vein to the point where the superficial 
hypogastric is given off by the femoral. The obliteration was 
caused by a coagulum of blood which adhered firmly to the 
sides of the vessel. The superficial hypogastric vein was con- 
siderably increased in size, and ascended as high as the um- 
bilicus, where it divided into three large branches that de- 
scended towards the femoral vein of the right side, after reu- 
niting into a single trunk similar to that which arose from the 
femoral vein of the left. The portion of the iliac vein that 
was obliberated was surrrounded by a mass of encephaloid 
matter. The subject of this observation was a woman, sixty- 
one years of age, who in her eighteenth year had had an attack 
of oedema in the lower extremity of the left side, and had ever 
since been subject to similar attacks in that limb. It is, there- 
fore, highly probable that the obliteration of the vein com- 
menced at the period when the dropsical affection first made 
its appearance. 

In another individual, affected with aneurism of the aorta, 
M. Reynaud* found the superior cava so compressed by the 
aneurismal tumour that its cavity was completely obliterated. 
The interior of the vessel, near its entrance into the auricle, 
was found occupied by cellular adhesions that united the sides 
of the veins together. These adhesions consisted of well or- 
ganized bands, similar in their texture to those cellular bands 



* Journal Hebdomadaire de Medecine, torn. 11. p. 84. 
f Journal Hebdomadaire de Medecine, torn. 11. p. 110. 



DISEASES OF THE VEINS. 259 

that often unite the pulmonary to the costal pleura. The veins 
on the lateral surface of the chest were remarkably developed 
and anastomosed freely with the epigastric vein, which was also 
considerably larger than usual. This extraordinary develope- 
ment of the superficial veins induced M. Reynaud to form his 
accurate diagnosis that the circulation was obstructed in the 
superior cava, and was carried on principally by the vena azy- 
gos and inferior cava. 

I have already alluded to the effects which result from the 
obliteration of the veins. The ingenious researches of M. 
Bouillaud have clearly proved that this obliteration is some- 
times the cause of dropsy. 

But few congenital lesions of nutrition have as yet been ob- 
served in the veins. Two superior venae cavae have been some- 
time found entering the right auricle; and the jugular vein has 
been seen arising directly from the same auricle. A still more 
remarkable deviation from the natural distribution, is that 
where one of the pulmonary veins is inserted into the venae 
cava ; the necessary consequence of this anomaly is the im- 
mediate return into the venous system of a portion of newly 
aerated blood. 



CHAPTER III. 



LESIONS OF SECRETION. 



The veins, like all other parts of the animal economy, are 
subject to depositions of that plastic organizable substance, 
which, whether extended into membranes, or condensed into 
amorphous masses, seems to be the origin of a great variety of 
morbid productions. 

In the veins this plastic substance is found deposited, 1, on 
their external surface, in which situation it may produce adhe- 



260 DISEASES OP THE VEINS. 

sions between the veins and the surrounding parts ; 2. between 
the coats of the vessel ; and, 3. in the interior of its cavity. 
When the circulation is interrupted by a ligature or any other 
cause, this plastic substance becomes organized, is converted 
into cellular tissue, and eventually obliterates the cavity of the 
vein. But, if the circulation in the vessel is not interrupted, 
the plastic substance lines its internal surface in the form of a 
simple albuminous layer without any trace of vitality, and in 
other instances, as M. Ribes was one of the first to point out, 
presents evident traces of organization, and is traversed by 
vessels of its own. Underneath these false membranes, the 
surface of the vein is sometimes found of a deep red, and some- 
times perfectly colourless. They may either be so circum- 
scribed as to form only a few small isolated patches, or so ex- 
tensive as to form an uninterrupted layer lining the entire of 
one, or even of several veins. In the veins, as in all other tis- 
sues, this plastic substance may gradually lose its physical 
characters, and be insensibly transformed into pus. This fluid, 
like the plastic matter of which, as already stated, it is only a 
modification, has been found, I. on the external surface of veins, 
2. between their coats, and, 3. within their cavity. 

The pus which is found in the interior of the veins may either 
have been formed there, or may have been introduced thither 
by the blood from some other point in the economy. It may be 
pure or mixed with blood. 

That the pus formed in an organ may be absorbed into the 
circulation, and carried with its vehicle the blood to a distant 
part of the economy, is now no longer a matter of doubt ; it is 
also highly probable that, in many instances where pus has been 
- found in the interior of venus coagula, it has been formed in 
these coagula in consequence of some peculiar modification of 
the blood itself. As I have already adduced several facts in 
support of both these opinions, I shall at present speak only of 
those cases where the pus has been formed by the veins in 
which it is found. 

The irritation which produces suppuration of the veins may 
arise without any appreciable cause ; this, however, is very 
rarely the case: more frequently it succeeds to some external 



DISEASES OF THE VEINS. 261 

injury, such as a puncture or ligature. In such cases, the irri- 
tation is almost invariably propagated from the injured point 
towards the heart, that is to say, in the direction of the circula- 
tion. 

The effusion of plastic matter or of pus into the interior of 
veins very frequently accompanies the active hyperaemia of the 
organs to which they belong. M. Ribes has repeatedly found 
the veins red, thickened, and lined with a false membrane, in 
parts affected with a simple erysipelatous or phlegmonous in- 
flammation. M. Velpeau has seen the femoral vein and its 
branches filled with purulent matter in women labouring under 
the disease called phlegmasia dolens. Pus has likewise been 
observed in the veins ramifying near diseased joints, unhealthy 
stumps, andfr a ctures. M.Louis and others have found the 
uterine veins laden with pus in several cases of acute metritis.* 
M. Gendrinf states, that in several cases of intestinal ulcera- 
tion, he observed the veins in the immediate neighbourhood of 
the ulcers filled with pus. The same author mentions his hav- 
ing found puriform matter in several of the veins of the brain, 
in a woman who died of acute encephalitis. In a case of ca- 
ries of the temporal bone, Abercrombie found the lateral sinus 
on the diseased side filled with pus. 

I have myself seen the vena porta? and its branches lined 
with a false membrane, in an individual whose intestines and 
liver were diseased ; and if we consider that the villi of the in- 
testines are (as M. Ribes has demonstrated) principally com- 
posed of minute branches of veins, it will appear highly prob- 
able that irritation of the veins plays a very principal part 
in several of those varieties of hyperaemia of the intestines 



* I have recorded several cases of this description in the Clinique Medicals. 
M. Dance in an interesting work on the subject just published, mentions his hav- 
ing found, in a great number of women who died shortly after delivery, the veins 
of the ovaries and uterus filled with pus ; and in some of these cases there were 
also collections of purulent matter in the lungs, spleen, joints, in the serous mem- 
branes, and even in the substance of some of the muscles. In some of these ca- 
ses, on bleeding the patient, he discovered pus in the veins of the arm likewise. 

f Histoire Anatomique des Inflammations. 



262 



DISEASES OF THE VEINS. 



where the redness is almost exclusively confined to the vil- 
losities. 

The different lesions of veins just enumerated may either 
succeed to various morbid alterations which had previously 
taken place in the other anatomical elements of the part, or 
may have been themselves the origin and source of those al- 
terations. Moreover, the irritation of the veins, whether prim- 
itive or consecutive, may exercise a remarkable influence on 
other organs at a distance from the real seat of the irritation. 
This influence may be produced, 1. by simple continuity of tis- 
sue, as when that portion of the liver or lung which imme- 
diately surrounds the affected vein participates in the disease ; 
2. by the pus being transported to distant organs, whether it is 
deposited in them, or merely circulates through them ; 3. by 
the mechanical obstacle which the diseased veins present to 
the venous circulation. 

There is another morbid secretion which though exceedingly 
common in arteries, is very rarely found in veins ; I allude to 
the calcareous matter. Morgagni and, after him, Bailie, found 
patches of ossified matter in the parietes of the vena cava. 
Beclard found the femoral vein ossified at a point where it 
came in contact with the femoral artery, which was itself sim- 
ilarly affected. Dr. Macartney, of Dublin, observed several 
depositions of calcareous matter in the parietes of the external 
saphena ; and I myself found in the parietes of the same vein 
a hard concretion, as large as a nut, and composed of phos- 
phate of lime. 

These calcareous concretions, instead of lying between the 
coats of the veins, sometimes push the internal membrane be- 
fore them, and project into the interior of the vessel : the mem- 
brane in such cases generally contracts behind the concretion, 
and forms a peduncle which serves to attach it to the side of 
the vein. It is probable that these peduncles are sometimes 
ruptured or absorbed, and thus the concretion is completely 
detached from its connexion, and drops loose into the vessel. 
This rationale may serve to explain the origin of some of those 
calcareous concretions which have been found in the centre of 



DISEASES OF THE VEINS. 263 

the venous coagula : it is, however, possible that they may 
have been formed in the blood itself. 

These concretions, which have received the name of plebo- 
lites, are of various sizes, some being scarcely larger than a 
grain of millet seed, and others as large as a pea. They have 
been found in the dilated veins of the inferior extremity of the 
rectum, bladder, uterus, ovaries, and testicles, and in some of 
the subcutaneous veins of the lower extremities. 

A substance perfectly analogous to healthy fat has been found 
in the parietes of the veins. I once saw a case of this descrip- 
tion, in which a tumour, presenting all the anatomical charac- 
ters of adipose tissue, was developed between the coats of the 
vena portae, near its entry into the liver. This tumour, which 
was about the size of a walnut, projected into the interior of the 
vein, and almost entirely obliterated its cavity. 

The vascular system in a number of animals not unfrequent- 
ly contains entozoa. In the horse, we often find both the 
strongylus and the filaria in the aorta and its branches, more 
especially in the superior mesenteric. In a porpoise that I 
had an opportunity of dissecting, I found the right ventricle of 
the heart and the pulmonary artery filled with a quantity of 
entozoa belonging to the class nematoidea of Rudolphi. In 
the human subject I know of only one case in which entozoa 
were really found in the vascular system. The case I allude 
to is detailed at length in my Clinique Medicale : the individ- 
ual who forms the subject of it died in the wards of La Cliariti, 
and on dissection we found the pulmonary veins filled with a 
great number of acephalocysts. 

We sometimes find gas developed in the veins. In the 
great majority of cases this is evidently the result of putrefac- 
tive process ; but I am inclined to think that, in some instan- 
ces, the gases found in the veins after death are not simply the 
result of putrefaction, for I have decidedly seen the blood 
frothy and containing a considerable proportion of air both in 
the veins and in the cavities of the heart, in bodies that were 
examined at a very short period after death, before they ex- 
hibited any symptom of incipient putrefaction. In these cases, 
the gas must either have been developed during life, or after 



264 DISEASES OF THE VEINS. 

the death of the individual ; but even on the latter supposition 
we must admit some peculiar condition of the blood, for under 
similar circumstances it does not usually present this ap- 
pearance. 

To conclude, the gases found in the vascular system are 
sometimes introduced from without. Some years ago, a man 
died suddenly at the Hospital Saint Antoine, just as the surgeon 
was concluding an operation on the lower part of his neck. 
On dissection, the jugular vein of that side, the superior cava, 
and the right side of the heart, were found distended by a large 
quantity of gas, possessing all the characters of atmospheric 
air. It was at the time supposed that the death of the patient 
was caused by the sudden introduction of the air into the heart 
through the orifice of a large vein which was divided and re- 
mained open during the operation ; and it was inferred that a 
similar accident would occur whenever any of the principal 
cervical veins were wounded, provided the orifice of the wound 
were held open by adhesions or other causes. In order to de- 
cide this question, MM. Magendie and Piedagnel instituted a 
set of experiments on living animals, by which they ascertained 
that when the jugular vein is cut across, and the cardiac orifice 
of the vein held open, the animal quickly dies, and on dissec- 
tion the veins and right side of the heart are found distended 
with air. 

It would appear that death is in these cases produced by the 
air which is admitted into the heart preventing that viscus from 
contracting properly : perhaps also the quantity of air which 
the heart drives into the pulmonary veins is particularly in- 
jurious to the action of the lungs. 

However that may be, this much at least is certain, that by 
introducing suddenly a large quantity of air into any part of the 
venous system, the animal is almost instantaneously killed; 
whereas a much larger quantity of air may be introduced with 
impunity provided it be done very slowly. 



DISEASES OF THE SPLEEN. 



SECTION IV. 



265 



DISEASES OF THE SPLEEN. 



In order to arrive at any thing like an accurate knowledge of 
the nature and seat of the diseases of this organ, it is absolutely 
necessary to have a correct idea of its anatomical structure. I 
shall therefore, before enlering on the subject of its morbid al- 
terations, briefly relate the result of my observations respecting 
its anatomy in the healty state. 

When the spleen is by repeated washing cleansed from the 
blood which it contained, it appears composed of an infinite 
number of cells communicating with each other and with the 
splenic veins. The communication between the cells and the 
splenic veins is accomplished in the following manner: the 
large branches formed by the primary division of the splenic 
vein are perforated by an infinite number of holes, which allow 
a probe introduced through the vein to pass immediately into 
the splenic cells , at a greater distance from the trunk these 
holes increase in size ; and at a still greater distance the venous 
coat ceases to form a continuous tube, and separates into fila- 
ments similar to, and continuous with, those by which the cells 
are formed. With respect to the artery, as soon as it enters 
the spleen it diminishes rapidly in size, and subdivides into 
small branches which seem to ramify on the walls of the cells, 
but it is impossible to follow them to their ultimate distribution. 
The splenic cells are formed by a number of fibrous filaments 
detached from the internal surface of the investing membrane 
of the spleen, and intersecting each other in every direction, 
leaving at each intersection certain intervals which constitute 
Vol. II. 35 



266 DISEASES OF THE SPLEEN. 

the splenic cells ; these fibrous prolongations terminate either 
by being inserted into the parietes of the vein, or by becoming 
continuous with the filaments that result from the subdivision of 
the venous parietes. They possess a considerable degree of 
contractility, and retract with force when cut across. 

To recapitulate, the spleen is composed of the following 
anatomical elements, besides its nervous and lymphatic ves- 
sels: 1. a fibrous tissue forming externally an investing mem- 
brane or capsule, and internally divided and subdivided into 
numerous sepia between which the blood is effused ; 2. a vein, 
which throughout its whole extent communicates with the 
splenic cells by an infinite number of holes pierced through its 
sides, and which ultimately has its cavity confounded with the 
cavities of the cells ; 3. an artery which immediately sub- 
divides into small branches that ramify on the septa of the 
cells, but of which the ultimate distribution as yet remains to 
be discovered.* 

Since the parenchyma of the spleen may be resolved into 
two component parts, the part contained, which is blood, and 
the part containing, which is fibrous tissue, it follows that the 
alterations to which this organ is liable should be sought for in 
one or other of these parts : in fact, its diseases ought to be the 
same as those of the veins ; for, after all, what is the spleen but 
a vast venous network in which the cellular is substituted for 
the vascular form 1 In the veins, the part containing is liable 
to but few morbid alterations, whereas the part contained, 
presents an infinite variety of modifications, which cannot be 
too attentively studied, for in them is to be found, unless I am 
greatly mistaken, the true secret of the origin and nature of a 
great number of morbid productions. The same modifica- 
tions may also be observed in diseases of the spleen ; for the le- 
sions of this viscus are, like those of veins, of two orders : those 
of the first, of comparatively rare occurrence, and of very minor 



* The structure of the spleen as I have described it, was known to several of 
the old anatomists. Winslow's description of its anatomical structure is almost 
precisely similar. 



DISEASES OF THE SPLEEN. 267 

importance, are seated in the capsule or in its fibrous prolonga- 
tions which constitute the walls of the splenic cells ; those of 
the second, much more important, and of much more frequent 
occurrence, are to be found in the matter contained in those 
cells. This matter, which is in fact coagulated fibrine, al- 
though not possessing any distinct organization, enjoys, per- 
haps, a greater sum of vitality than the fibrous tissue which 
contains it, and consequently is more prone to become irrita- 
ted and altered in its nutrition, and to separate from its own 
substance various morbid productions. 



CHAPTER I. 



Diseases of the Spleen which have their Seat in the Mattel- con- 
tained in its Cells. 



These diseases are referable to alterations either of nutri- 
tion or secretion ; but it is in many cases difficult to decide on 
which of these two alterations the disease depends ; whether, 
for instance, the tubercles that are developed in the fibrine 
with which the cells are filled are separated from that fibrine 
by an act of secretion, or whether they are produced by a sim- 
ple alteration in the internal arrangement of the fibrinous par- 
ticles. 



268 DISEASES OP THE SPLEEN. 



ARTICLE I. 

ALTERATIONS IN THE CONSISTENCE OP THE SPLEEN. 

These alterations evidently depend on a change in the con- 
sistence of the blood which fills the splenic cells. 

Authors have described as softening of the spleen, that con- 
dition of the viscus, in which the blood contained in its cells has 
so lost its natural consistence, that it may easily be washed 
away, leaving behind it the cellular parenchyma of the spleen 
in a state of perfect integrity. In some cases of this descrip- 
tion, the blood is found perfectly fluid, and the external surface 
of the spleen gives an indistinct sensation of fluctuation. The 
spleen, when in a state of softening, may either preserve its 
usual size, or be diminished, or, on the contrary, enlarged. 
The third case is by no means of rare occurrence ; indeed it is 
one of the anatomical characters most constantly found in con- 
tinued fevers attended with adynamic symptoms. 

Induration of the spleen (such at least as is commonly ob- 
served) is likewise caused by a modification in the qualities of 
the blood contained in its cells. The blood in these cases is 
particularly dense and gives to the spleen when divided the ap- 
pearance of a slice of liver, or of a muscle that has undergone a 
certain degree of congelation. 



ARTICLE II. 



ALTERATIONS OF SIZE. 



The variations in the size of the spleen depend on the same 
cause as the changes in its consistence, that is to say, on the 



DISEASES OF THE SPLEEN. 269 

blood contained in its cells ; whether that fluid, being constantly- 
deposited by the arteries, is not removed in sufficient quantity 
by the veins, and is thus simply accumulated there : or being 
once deposited, and having become endowed with life, it ac- 
quires the faculty of nourishing itself by intussusception, and, 
by the increased activity of its nutrition, produces the hyper- 
trophy of the organ. 

When the spleen is preternaturally increased in size, it occu- 
pies a larger space and consequently a different position from 
that in which it is usually found. Sometimes it ascends into 
the left hypochondrium, thrusts the diaphragm before it, and, 
applying itself exactly to the internal surface of the ribs, pro- 
duces as dull a sound on percussion over the left hypochon- 
drium, as is produced in the right by the presence of the liver. 
In some cases of this description, the spleen does not project 
beyond the cartilaginous margin of the ribs, so that without the 
aid of percussion it would be impossible to detect its enlarge- 
ment. In other cases the spleen projects beyond the ribs, and 
forms a tumour which is liable to considerable variety in its 
form and dimensions. This tumour may occupy, 1. the left 
hypochondrium; 2. the left flank; 3. the epigastrium; 4. the 
umbilicus; 5. it may even extend towards the right flank and 
occupy the hypogastrium or the iliac fossae. 

The spleen sometimes forms a tumour without being increas- 
ed in size, in consequence of being thrust out of its place by a 
pleuritic effusion pushing the diaphragm downwards towards 
the hypochondrium. 

The size of the spleen is also liable to considerable diminu- 
tion: I have seen it no larger than a walnut. In this case, as 
in the preceding, the consistence of the fluid contained in its 
cells may remain unaltered, or may be either increased or di- 
minished. Of the circumstances which tend to produce this 
atrophy of the spleen we are totally ignorant. 



270 



DISEASES OF THE SPLEEN. 



ARTICLE III. 



ALTERATIONS OF COLOUR. 



The spleen sometimes presents, instead of its natural colour 
either a bright red, or a deep black tint ; this may occur only 
in scattered points, and the organ then assumes a mottled ap- 
pearance. 

In other cases, it assumes a whitish or yellowish tint in cer- 
tain portions of its extent. The white or yellow masses thus 
formed may be either of the same consistence with the rest of 
the organ, or harder, or, on the contrary, quite soft and pulpy. 
It is evident from what we have seen occurring in the veins, 
that this merely arises from changes in the colour and consist- 
ence of the blood contained in the splenic cells, and not from 
the formation of any new production. 



ARTICLE IV. 



NEW PRODUCTIONS. 



I think it highly probable that ere long it may be demon- 
strated that the different morbid productions which I am now 
about to describe are nothing else than the blood contained in 
the splenic cells modified in its qualities. The experiments of 
M. Gendrin, to which I have already had occasion to allude, 
seem to prove that the blood may be converted into pus. The 
result of my own observations has quite convinced me that, by 



DISEASES OF THE SPLEEN. 271 

a simple alteration in its colour and consistence, it may be con- 
verted into a substance perfectly analogous to the encephaloid 
tissue described by Laennec. Let us go a little farther, and 
suppose the blood in small circumscribed masses deprived of 
its colour, and diminished in its consistence, so as to become 
curdy and friable, and we have then all the essential characters 
of tubercle. 

Pus has been occasionally observed in the spleen ; it appears 
either in isolated drops dispersed through its parenchyma, or 
collected into abscesses of greater or less extent. These pur- 
ulent collections may be separated from the surrounding parts 
by a false membrane, or may pass insensibly into the sound 
parts. The abscesses not bounded by any distinct cyst some- 
times acquire a very great size : I saw a case in which three- 
fourths of the splenic parenchyma were filled with pus ; the 
fibrous tissue remained unaltered in some points, and in others 
was soft, pulpy, and easily broken down; the capsule itself had 
become friable in those points where it was in immediate con- 
tact with the pus, and it is highly probable that if the individ- 
ual had lived, the pus would have found its way into the sac of 
the peritoneum. There are several cases on record of ab- 
scesses of the spleen terminating in this way ; they have also 
been known to burst into the stomach, the colon, the thorax, 
and the urinary passages ; and some have been described as 
making their way through the muscles of the abdomen, the 
back, or the loins and bursting externally. 

The formation of pus in the spleen often takes place at the 
same time that it is deposited in other parenchymatous struc- 
tures. In those cases it is probable that the pus is formed else- 
where, and only deposited in the spleen, as it is in the other 
organs. In a woman who died at La Charite, and on dissec- 
tion exhibited a number of small abscesses in the spleen, lungs, 
liver, and brain, it appeared that the uterus was the organ in 
which the pus was originally formed; for the symptoms of met- 
ritis were those first presented, several collections of puriform 
matter were found in the substance of the uterus, and all the 
uterine veins were filled with pus. 



272 DISEASES OF THE SPLEEN. 

The cases where purulent matter is found only in the spleen, 
and where the disease, terminating in suppuration, is originally 
seated in that organ, are perhaps more rare than the preceding. 
One of the most remarkable cases of this description is that of 
a child three years old, whose spleen was literally converted 
into a cyst full of pus. The child had, during life, complained 
of violent pain in the left hypocondrium, accompanied with 
continued fever, and symptoms of irritation of the meninges. 
In this case the suppuration of the spleen gave rise to the usual 
train of symptoms which proceed from irritation of the gastro- 
intestinal membrane, but on dissection the whole of the aliment- 
ary canal was found perfectly healthy, as was also the brain. 

Instead of pus, it is much more common to find tubercular 
matter in the spleen, generally in the form of minute grains 
isolated or clustered together. Tubercles of the spleen are 
very rare in adults; they are more common in children, but 
are seldom found at any age unless when they exist in other 
organs at the same time. 

Tubercles are common enough in the spleen of certain ani- 
mals : I have repeatedly found them in the horse; and M. Rey- 
naud ascertained by dissecting several monkeys that died at the 
menagerie at Paris, that although tubercles are excessively 
common in the lungs of those animals, they are still more com- 
mon and more numerous in the spleen. 

Cysts of various descriptions are also occasionally developed 
in the spleen; their simplest form is that of small vesicles filled 
with serous fluid, which are sometimes found in great numbers 
either singly or in clusters. These vesicles are not confined 
to the splenic cells; I have also found them in the interior of 
the splenic veins, some floating loose, others attached by pe- 
duncles to the sides of the veins, and others again lodged be- 
tween their coats. 

Cysts of much more complicated structure are likewise 
formed in the spleen. I hare seen one with a fibro-serous 
tunic which contained in its interior a substance resembling 
suet, interspersed with hairs. I„ another spleen I fonnd a cyst 
composed of serous membrane, filled with a substance like 
honey, and of a bright yellow colour. 



DISEASES OF THE SPLEEN. 273 

Lastly, hydatic cysts are sometimes developed in the spleen, 
less frequently, however, than in the liver. As their mode of 
developement in this viscus differs in no respect from that in 
other organs, it is unnecessary to enter here into any particular 
description of them. 



CHAPTER II. 



Diseases of the Spleen affecting its Fibrous Tissue. 



The morbid alterations which seem to affect principally the 
fibrous tissue of the spleen may be divided in those which at- 
tack its capsule, and those which are seated in the parietes of 
the splenic cells. 

The alterations of the capsule consist, 1. in an unusual injec- 
tion of its vessels; 2. in its softening, which may even proceed 
so far as to occasion its rupture; 3. in its thickening; 4. in its 
transformation into cartilaginous or osseous tissue. 

The alterations of the fibrous tissue which forms the walls of 
the splenic cells are as yet but little known. It has been ob- 
served, 1. in a state of softening; 2. in a state of hypertrophy, 
so as to render the septa more numerous, or thicker, and con- 
sequently more apparent than in the natural state ; 3. partially 
transformed into cartilaginous or osseous tissue. I once found 
the spleen transformed into a mere osseous shell; the com- 
partments into which its interior was divided were likewise 
converted into bone, and contained only a small quantity of 
reddish fluid like muddy wine. 



Vol. II. 36 



274 DISEASES OF THE SPLEEN. 



CHAPTER III. 



Nature and Causes of the Alterations of the Spleen. 



The various morbid alterations of the spleen already de- 
scribed, may be divided into several classes, according to the 
nature of their origin. 

Some evidently originate in irritation; but there are not 
many belonging to this class. Others depend on a simple 
modification in the nutrition either of the parts containing, or 
of the parts contained. Among these is softening, which, in 
most cases at least, depends on some alteration of the whole 
mass of blood, as is proved by its being chiefly observed in 
cases of scurvy, and of adynamic or putrid fever. Others, 
such as enlargement, and induration, appear to arise from some 
obstruction to the venous circulation. Thus, the spleen often 
remains enlarged after agues ; and becomes enlarged and in- 
durated in many cases where the passage of the blood through 
the vena portse is obstructed by disease of the liver. 

Lastly, others, such as pus, tubercle, &c. appear to result 
from a general tendency to their formation in the system, or 
to have been brought there and deposited by the blood in the 
course of its circulation. 



DISEASES OP THE LYMPHATIC SYSTEM. 275 



SECTION V. 



DISEASES OF THE LYMPHATIC SYSTEM. 

If we were to judge of the number of morbid alterations 
which this system presents to the anatomist, from the number 
of works written on its diseases, we should suppose that few 
parts of the body were so frequently found diseased. The 
contrary, however, is the fact ; and the morbid changes either 
of the lymph or of its containing vessels that are appreciable 
on dissection, are exceedingly rare and altogether different 
from the descriptions given of them in books of speculative 
medicine. The structure and functions of the lymphatic gan- 
glions are as yet by no means well understood, but their dis- 
eases (at least such as are appreciable to the anatomist) are 
much more common than those of the lymphatic vessels. 

I shall now proceed to describe in order the morbid altera- 
tions, 1. of the lymphatic vessels ; 2. of the lymph ; and, 3. of 
the lymphatic ganglions. 



276 DISEASES OF THE LYMPHATIC SYSTEM. 



CHAPTER I. 



Diseases of the Lymphatic Vessels. 



I have examined the thoracic duct and principal lymphatic 
vessels in six hundred and odd subjects, and found but in a very 
few instances any appreciable alteration in the parietes of these 
vessels. 

In three cases only, the parietes of the thoracic duct appear- 
ed to me red and injected, and in one of these the interior of 
the duct was filled with pus, and its coats were thickened and 
friable. 

The following case is still more rare than the preceding : I 
never observed it but in one instance, and am not acquainted 
with any other on record. A woman died at La Charite, 
with cancer of the uterus. On dissection, the thoracic duct 
was found considerably enlarged, and of a dead white colour : 
it was filled with a puriform fluid, and its internal surface was 
studded with an infinite number of round white bodies about 
the size of peas, in the intervals between which the parietes of 
the duct were much thickened, and presented a dead white 
colour, traversed here and there by reddish lines, and in other 
points were reduced to a soft pulp of a dirty reddish white. 
The left subclavian vein, into which the duct opened freely, 
was distended by a number of dense firm clots of blood, which 
had contracted an intimate adhesion to the coats of the vein, 
the inner surface of which was wrinkled and of a deep brown 
colour. In this woman, the cervix uteri was converted into a 
black putrid matter, and large masses of cancer were devel- 
oped in the pelvis, in the mesentery, and over all the lumbar 
vertebra?, where they completely enveloped the tributary 
branches of the thoracic canal. 



DISEASES OF THE LYMPHATIC SYSTEM. 277 

The thickening of the walls of the thoracic duct may pro- 
ceed so far as to produce a partial or even total obliteration of 
its cavity. I once saw it converted into an impermeable 
fibrous cord, for a space corresponding to the third, fourth, 
and. fifth dorsal vertebra? ; above this point it again became 
permeable, and was filled with lymph from a vessel of consid- 
erable size that came off from the duct a few lines below the 
point where it was obliterated, and re-entered it a short dis- 
tance after it again became permeable, thus establishing a col- 
lateral circulation. 

I have observed in the lymphatic vessels several of the same 
alterations as I have just described in the thoracic duct. On 
opening the body of a phthisical patient who died at La Charite, 
I found on the external surface of the intestines, over where 
they were ulcerated internally, the lymphatic vessels remark- 
ably white and hard, and so dilated at intervals as to resemble 
a string of rounded nodules. At first sight, I mistook them for 
a series of tubercular grains, but, on cutting into them, I found 
that they were formed by the thickening of the coats of the 
lymphatic vessels ; from the knotted appearance which these 
vessels presented, it is probable that the thickening and indu- 
ration of the coats was principally confined to the neighbour- 
hood of the valves. There was no morbid matter whatever 
contained in their interior. 



CHAPTER II. 



Alterations of the Lymph. 



Instead of the natural fluid which the thoracic duct and 
lymphatic vessels usually contain, a variety of .other sub- 
stances both fluid and solid are occasionally found. In some 



278 DISEASES OF THE LYMPHATIC SYSTEM. 

cases these substances appear to have been formed there ; in 
others they seem merely introduced by absorption. 

A fluid similar to blood has been found in the lymphatic ves- 
sels : Mascagni relates several cases of sanguineous effusion 
from the pleura and peritoneum, where the lymphatics rami- 
fying on these membranes were distended with blood. We 
must bear ir^ mind, however, that the lymph contained in the 
thoracic duct not unfrequently presents a rosy tinge, or even a 
deeper shade of colour, and that the same appearance has also 
been observed in some of the lymphatics in cases where there 
was no reason to suppose any admixture of blood. M. Ma- 
gendie has lately discovered that the lymph invariably presents 
a shade of rose-colour whenever an animal has been kept long 
fasting previously to examination. 

M. Dupuytren, several years ago, found the lymphatics of 
one of the lower extremities filled with pus, in the case of a 
man who had a large purulent abscess on the leg. For a long 
time this remained a solitary observation ; but within the last 
two or three years several instances have been met with of pus 
contained in the lymphatic vessels. Besides the case related 
in the last chapter, I found in another instance the thoracic 
duct filled with pus in a woman who had suppuration of one of 
the veins ; the coats of the duct were at the same time red and 
friable. M. Velpeau has found purulent matter in the lym- 
phatics of the lower extremities in women labouring under the 
disease called phlegmasia dolens. I have seen several instan- 
ces of the lymphatics arising from ulcers of the intestines being 
filled with a fluid presenting all the characters of pus. The 
same remark has been also made by Soemmering and M. Gen 
drin. According to Mascagni, it is by no means uncommon 
to find pus in the lymphatics of the lungs in phthisical subjects : 
my own observation has not confirmed this assertion. In a 
case of gangrene of the lo.wer extremities, Dr. Lauth of Stras- 
burgh states that he found the lymphatics up to the thoracic 
duct filled with a sanious matter similar to that which existed 
in the gangrenous parts. 

I have repeatedly found in the lymphatics a white curdy sub- 
stance like tubercle. The thoracic duct was filled with mat- 



DISEASES OF THE LYMPHATIC SYSTEM. 279 

ter of this description in a woman who died at La Charitt in 
1824, of cancer of the womb. It is not very uncommon to 
find this substance in the lymphatic vessels of ulcerated intes- 
tines in phthisical women. In these cases the lymphatics ap- 
pear like so many knotted white cords passing from the intes- 
tines towards the mesentery. I recollect a case where a sub- 
stance presenting all the characters of tubercle filled at the 
same time, 1. several of the inguinal lymphatics ; 2. the pelvic 
lymphatics ; 3. the superficial lymphatics of the lungs ; and, 4. 
the thoracic duct. The subject of this observation was a wo- 
man who died of cancer of the uterus. The ganglions of the 
mesentery and those of the pelvis were converted into enor- 
mous masses of cancer. The ganglions of the axilla and those 
which surround the bronchi before their entrance into the lung, 
were likewise cancerous and greatly enlarged. 

Mascagni and Saunders say that they have found a fluid simi- 
lar to bile in the lymphatics of the liver : I have never seen 
this appearance myself, but I have repeatedly observed a re- 
markable yellow tinge in the lymph contained in the thoracic 
duct of icteric patients. 

According to Soemmering, masses of calcareous phosphate 
have been found in the lymyhatic vessels, and M. Lauth speaks 
in his Thesis of a case of caries of the iliac bones where the 
lymphatics of the pelvis were found filled with osseous matter. 

We have already seen that the thoracic duct may be oblite- 
rated by the thickening or other morbid alteration of its coats : 
its cavity may likewise be obstructed by a variety of morbid 
substances, either formed in its interior or brought there by 
absorption ; and lastly its obstruction may proceed from the 
pressure exercised on it by external tumours. 

When the thoracic duct is obliterated, the circulation of the 
lymph may be kept up by a variety of supplementary passages. 
The principal of these are the following : — 

1. The great lymphatic trunk of the right side. 

2. Collateral branches arising from the duct below its oblite- 
ration, and re-entering it above that point. 

3. A second thoracic duct arising from the receptaculum 
chyli, and ascending parallel to the other, without communi- 



280 DISEASES OF THE LYMPHATIC SYSTEM. 

eating with it, until it arrives near the left subclavian vein, 
where the two ducts unite and enter the vein by a single 
trunk. 

4. Large lymphatic vessels opening directly into different 
parts of the venous system. The researches of modern anato- 
mists have discovered a considerable lymphatic vessel open- 
ing occasionally into a vena azygos, another equally large open- 
ing into the vena cava near the third lumbar vertebra, and 
likewise other lymphatics that pour their contents into the com- 
mon iliac, the splenic, mesenteric, and renal veins, and like- 
wise into the vena porta?. These communications between 
the lymphatic and venous systems are much more visible in the 
bird tribe than in the human subject. 

5. Lastly, it is admitted by anatomists that the lymphatics 
communicate with the veins in the interior of the ganglions, and 
at their origin in the different parenchymatous structures. 



CHAPTER III. 



Diseases of the Lymphatic Ganglions. 



The lymphatic ganglions are formed of two distinct compo- 
nent parts, 1. lymphatic vessels variously convoluted, and 2. 
cellular tissue serving to unite those convolutions. This con- 
voluted structure may be demonstrated in the human subject 
by injection, and is evident of itself in certain animals in which 
the cellular tissue disappears, and the glandular structure is re- 
placed by plexuses evidently composed of an infinite number 
of lymphatic vessels mutually intertwined. It is therefore in 
these two anatomical elements that we are to look for the mor- 
bid alterations of the lymphatic ganglions. 



DISEASES OF THE LYMPHATIC SYSTEM. 281 

These alterations do not occur with equal frequency at eve 
ry period of life ; they are most common at that age when the 
ganglions are most developed, and their function most active, 
namely in infancy. 

Dr. Boeker, a German anatomist, states that he repeatedly 
injected with mercury lymphatic ganglions presenting different 
forms of morbid alteration, and that he invariably found the in- 
jection pass freely through all the convolutions of the vessels ; 
whence he concludes that in the diseases of these ganglions, 
the lesion is, at least in the great majority of cases, confined to 
the cellular tissue that unites the convolutions of the vessels, or 
to the coats of those vessels, but that there is no obstruction of 
their cavity. 

Active hyperaemia (inflammation) occurs frequently in the 
lymphatic ganglions, and may be either acute or chronic, con- 
fined to one ganglion, or extending to several. The lymphatic 
ganglions, when inflamed, are red, tumified, and soon become 
friable. 

These ganglions are also subject to hypertrophy, in which 
state they acquire a considerable increase of size and hardness, 
and at the same time either become perfectly colourless, or 
else acquire a red or brown tint. The white induration of the 
lymphatic ganglions has been described by authors as their 
conversion into scirrhus; in this state they present a homoge- 
nous hard tissue, of a dead white or pearly appearance, 
and grating under the scalpel. A few red vessels some- 
times appear in this tissue ; they are not, however, (as general- 
ly described.) vessels of new formation, but a remnant of the 
natural vascularity of the part. 

The lymphatic ganglions are frequently the seat of different 
morbid secretions. 

In the first place, they occasionally suppurate : in which case 
the pus either infiltrates their tissue, giving it a dirty grey 
colour, or is disseminated in small isolated drops, or is collect- 
ed into an abscess, which in some cases occupies the entire 
gland, and destroys all traces of its parenchymatous structure, 
the cellular envelope of the ganglion alone remaining and form- 
ing a cyst to the abscess. Sometimes the disease proceeds 

° Vol. II. 37 



282 DISEASES OF THE LYMPHATIC SYSTEM. 

still further, and the envelope itself ulcerates and allows the pus 
to escape. 

There are fewer parts of the body where tubercular matter 
is more frequently deposited than in the lymphatic ganglions. 
It appears in the same varieties of form as the purulent matter 
of which we have just spoken ; namely, infiltrating the whole 
substance of the ganglion, occurring only in some isolated points, 
or occupying the whole of it. The lymphatic ganglions are one 
of the parts which best exhibit the developement of tubercle 
subsequently to an attack of inflammation ; but though in many 
cases the tuberculated gland presents unequivocal marks of an- 
tecedent congestion or inflammation, it is not the less true that 
in several instances there exists no evidence whatever of the 
formation of the tubercular matter having been preceded or 
accompanied by any species of hyperaemia. 

I have, in deference to the generally received opinion, de- 
scribed tubercle in the lymphatic ganglions as the product of 
secretion, though I am disposed to think the day is not far dis- 
tant when it will be proved to derive its origin from a different 
source ; perhaps it may yet be considered as simply the result 
of an alteration of the lymph itself, either spontaneous, or caus- 
ed by a morbid condition of the lymphatic vessels, Or perhaps 
resulting simply from its stagnation caused by some mechanical 
obstacle to its circulation through the lymphatic plexus. 

Melanosis is in like manner frequently deposited in the lym- 
phatic ganglions. A great proportion of the melanic tumours 
described by authors in the human subject and in animals, ap- 
pear to be nothing else than lymphatic ganglions coloured 
black. 

These ganglions likewise occasionally contain calcareous 
phosphate. Sometimes it appears like grains of sand mixed up 
with tuberculous matter, and sometimes the whole ganglion is 
metamorphosed into an earthy mass, which on analysis pre- 
sents scarcely a trace of animal matter. 

We seldom find these depositions of calcareous matter in the 
lymphatic ganglions but at an advanced period of life ; there 
are, however, exceptions. In a boy whose age certainly did 
not exceed sixteen years, I found in the ganglions around the 



DISEASES OF THE LYMPHATIC SYSTEM. 283 

bronchi, and in those of the mesentary and pelvis, a number of 
chalky concretions mixed with a fatty matter like suet. His 
lungs likewise contained a number of these concretions ; and 
what rendered his case particularly remarkable, was the fact of 
his having a large abscess in one of the iliac fossse, with con- 
siderable destruction of the iliac bone. Now the question nat- 
urally presents itself, Was there any connexion between the 
deficiency of the earthy substance in the diseased bone, and its 
accumulation in the ganglions ? I am not prepared to assert 
that there was ; I shall, however, relate the following case, and 
leave the reader to form his own opinion. 

A woman, aged only thirty-three years, died at La Charite, 
of an acute attack of pleuritis, which supervened during the 
course of a chronic pulmonary affection. On opening the body, 
we found the bodies of six vertebra? (the last dorsal and five 
lumbar) completely destroyed. We also found calculous con- 
cretions, 1. in the lymphatic ganglions of the neck ; 2. in those 
placed between the trachea and oesophagus, and between the 
oesophagus and vertebrae ; 3. in the bronchial ganglions ; 4. in 
those which occupy the fissures of the liver and spleen ; 5. in 
those of the pelvis ; 6. in those of the axilla : and, 7. in the in- 
guinal ganglions. The lungs likewise contained a number of 
these concretions. 

In this case, as in the preceding, there was a coincidence be- 
tween the deficiency of a certain quantity of osseous matter 
where it should naturally be deposited, and the deposition of 
this matter in those parts where it does not usually exist. In 
both cases, the calcareous deposition was found in the same 
parts, the lymphatic ganglions and lungs ; and lastly, it was in 
that case where the loss of osseous matter was greatest, that the 
calcareous depositions were the most numerous and most ex- 
tensive. M. Reynaud informs me that he observed another 
case at La Charite analagous to the preceding. 

These facts may at least induce us to hesitate and consider a 
little, before we adopt as infallible the doctrine which consid- 
ers every deposition in the ganglions, whether of calcareous 
matter, tubercle, or melanosis, as the product of local irritation, 
the existence of which can, in many cases, only be inferred 



2S4 DISEASES OF THE LYMPHATIC SYSTEM. 

from analogy. The fact is, that but in very few cases should 
the cause of the morbid alteration of the lymphatic ganglion 
be sought for in the ganglion itself. I do not at present allude 
to those cases where the ganglion becomes diseased in conse- 
quence of some irritation of the part from which its lymphatics 
arise, as when disease of the mesenteric glands succeeds to ir- 
ritation of the mucous membrane of the intestines ; but I wish 
to call the attention of my readers to those cases where the af- 
fection of the lymphatic glands is only one of the effects of a 
general cause, which at the same time exerts its influence on the 
most remote parts of the body, and produces the train of symp- 
toms which usually characterize the scrofulous diathesis. 

The lymphatic ganglions, when once they have become dis- 
eased, may derange the structure or functions of the surround- 
ing parts, either by the irritation they communicate, or by the 
mechanical pressure they exert. In the chest, for instance, 
the bronchial ganglions sometimes compress the bronchi so for- 
cibly as to impede the passage of the air into the lungs. M. Rey- 
naud shewed me a remarkable instance of this, in the thorax of 
a monkey, where an enormous ganglion filled with tubercular 
matter, had so compressed the main bronchial tube of one of 
the lungs, that its cavity was almost completely obliterated, the 
lung to which it was distributed had undergone a remarkable 
degree of atrophy, and the thoracic parietes of that side had con- 
tracted and fallen in, as in the case of absorption of a pleuritic 
effusion. 

The diseased ganglions, instead of compressing the bronchi, 
may excite in them such a degree of irritation as to produce 
their perforation, and thus establish a free communication be- 
tween the bronchial tube and the interior of the diseased gan- 
glion. If the latter be in a state of suppuration, the pus which 
it contains may in this way find an exit, and recovery ensue : 
the same may happen if, instead of pus, the ganglion contains 
tubercle ; only, in the latter case, recovery will more rarely 
follow, inasmuch as tubercles are seldom developed in the bron- 
chial glands unless when they also exist in the lungs ; I have, 
however, more than once seen instances of their being so. I 
once saw a bronchial ganglion filled with calcareous deposi- 



DISEASES OF THE LYMPHATIC SYSTEM. 285 

tions, which communicated with the interior of one of the bron- 
chi. The orifice of the communication was round, and its bor- 
der smooth and black. The subject of this observation was an 
old woman, who had laboured under cough for a series of 
years ; it is evident that she might have expectorated calculi 
which did not come from the lungs. 

In the abdomen, the lymphatic ganglions may, simply by the 
mechanical pressure they exert when enlarged, give rise to a 
variety of morbid phenomena. Thus, when developed in 
enormous masses round the pylorus, they sometimes compress 
it so forcibly as to produce all the symptoms usually attendant 
on scirrhus of that portion of the stomach. When accumulat- 
ed round the hepatic duct, they compress its parietes, the bile 
no longer flows into the duodenum, and jaundice ensues. I 
have seen these ganglions occupying the place of the gall- 
bladder, which they had so compressed as to produce its al- 
most total obliteration. In other cases the ureters are nearly 
obliterated by the pressure they sustain from them ; and lastly, 
the vena cava is sometimes so compressed, and its circulation 
so impeded, that the lower extremities become cedematous, in 
consequence of the obstacle thus presented to the venous 
circulation. 



286 RESPIRATORY APPARATUS. 



RESPIRATORY APPARATUS. 



In order to have a general idea of the respiratory apparatus, 
we must imagine a surface of considerable extent placed in 
constant contact with the external atmosphere, and traversed 
by an infinite number of blood vessels and nerves. The pur- 
pose of this apparatus is to produce certain modifications in the 
blood by exposing it to the air, for the purpose of eliminating 
certain principles from the blood, and absorbing others from 
the air. The respiratory apparatus performs the functions of 
absorption and exhalation throughout its whole extent, but it is 
only in its more minute subdivisions that the air begins to pro- 
duce its peculiar effects on the blood ; so that, in this respect, 
the apparatus may be considered as consisting of two parts ;* 
of which one, being destined to convey the blood without af- 
fecting its qualities, is composed of tubes of large diameter ; 
and the other, in which the blood and the air mutually modify 
each other, is only the continuation of the former, but the tubes 
are subdivided, and consequently become much smaller and 
more numerous, until each of them terminates in a cul-de-sac, 



* Even in the primary divisions of the bronchi, we sometimes find a few laminse 
or folds projecting from the internal surface, with a fine vascular network spread 
over them. These folds are analogous to the incomplete septa which arise from 
the internal surface of the vesicular pouch that serves as a lung in the frog tribe. 
It is not impossible that they may serve to expose the blood to the action of the 
air in the bronchi. 



RESPIRATORY APPARATUS. 287 

or air cell, as it is generally called. These air cells and the 
minute tubes of which they are the terminations, united to- 
gether by cellular tissue in which run the vessels and nerves 
that are distributed to them, constitute the pulmonary paren- 
chyma. This anatomical arrangement may be demonstrated 
in a variety of ways : 

1. Reisseissen, by injecting mercury into the bronchial tubes, 
converted the lung into an assemblage of vesicles distended, 
each, by a globule of mercury, and without any direct commu- 
nication with one another. 

2. If we examine in a strong light a portion of lung contain- 
ing only a small quantity of blood, we perceive on its surface 
an innumerable quantity of minute vesicles filled with air, and 
separated one from the other by cellular tissue. 

3. If we take a lung as free from blood as possible, and force 
the air gently towards its margin, we observe a number of 
minute tubes filled with air, which, at their extremities and 
laterally, present a series of vesicles ("renflemens") having no 
communication with one another, and in every respect similar 
to the vesicles filled with mercury represented in the admi- 
rable plates of Reisseissen. This arrangement of the air cells is 
particularly evident in those cases where the pulmonary tissue 
is rarefied. M.Reynaud and I have repeatedly observed it in 
the human subject ; but it is still more evident in some of the 
mammalia, especially in the monkey tribe. 

4. In certain morbid conditions, the pulmonary vesicles di- 
late, and become quite apparent to the naked eye. 

The cellular tissue, as we have already seen, isolates the air 
cells from each other, and likewise the lobules, which consist 
of a parcel of these air cells formed by the subdivision of one 
or more small bronchial tubes. These lobules are to the 
lobes what the latter are to the whole lung. It is important to 
fix our attention on the anatomical isolation, first, of the air 
cells, then, of the lobuIes,'and lastly, of the lobes; inasmuch as 
these different parts are frequently isolated in disease, so that 
one air cell or one lobule may be affected, without the disease 
necessarily involving the adjacent air cells or lobules. 



288 RESPIRATORY APPARATUS. 

The number of the air cells is not the same in all persons; 
and hence result the various degrees of density which the lungs 
present in different persons, and even in the same person at 
different periods of life. It is directly proportional to the 
quantity of blood to be aerated in a given time. For example, 
the pulmonary parenchyma has its maximum of density in those 
animals whose circulation is habitually rapid, as in birds; on the 
contrary, it is at its minimum of density in those animals whose 
circulation is very slow, or in whom the whole mass of blood 
does not pass through the lungs at each round of the circulation, 
as in reptiles. Even among the mammalia there is a consider- 
able variety in the degree of their pulmonary density, or in 
other words, in the number of their air cells. In the horse, the 
density of the lung is very great; in the dog it is also consid- 
erable; and in both these animals it is greater than in man. 
The human lung has the greatest possible number of air cells 
during infancy; consequently it is then at its maximum of den- 
sity, and resembles the lung of the horse. On the contrary, in 
old age, the number of air cells is considerably diminished, and 
the lung then becomes so rarefied as to bear some analogy to 
the lung of reptiles. This atrophy of the lung, which is a nat- 
ural condition in old age, may likewise occur as a morbid alter- 
ation at other periods of life: and in that character I shall pres- 
ently describe it more fully. 

The foregoing observations suggest a natural division of the 
diseases of the respiratory apparatus ; for, in its pathological 
alterations, as well as in its physiological functions, this appa- 
ratus presents two distinct parts, one which conveys the air to 
the blood, the other where the blood is elaborated by the air. 
In both these parts, however, the seat of disease is the same: 
in the air cells, as in the larynx, the disease must be situated 
either in the different anatomical elements which compose their 
parietes, in the cellular tissue exterior to these parietes, or in 
the matter contained within their respective cavities. But, the 
form of a larynx or of a large bronchial tube is not the form of 
an air cell; hence arises a difference in the form of the morbid 
alteration: neither are the anatomical elements of the large air 



RESPIRATORY APPARATUS. 289 

tubes the same as those of the air cells; and hence a difference 
in the very nature of these alterations: lastly, the functions of 
the two parts are essentially different ; and hence a considera- 
ble difference of the importance of their diseases, and in the 
symptoms which attend them. 



Vol. II. 38 



290 DISEASES OP THE AIR TUBES. 



SECTION I. 



DISEASES OF THE AIR TUBES. 



Under this title, I include the diseases of the larynx and 
trachea, and of the bronchia as far as they can be traced with 
the scalpel: beyond this point, the parenchyma of the lung 
commences. 



CHAPTER I. 

Lesions of the Mucous Membrane. 

The morbid conditions of this membrane are identical from 
the glottis to the minutest ramifications of the bronchia. 
Throughout its whole extent it is liable to alterations in its cap- 
illary circulation, nutrition, and secretion; and I think, we 
shall form a more comprehensive, and at the same time a more 
accurate idea of these alterations, by not separating in our de- 
scription the alterations of the larynx and trachea from those of 
the bronchia. A false membrane is still the same, whether 
produced in the bronchia, or in the glottis; the symptoms, it is 
true, are different, but the morbid alteration is essentially the 
same in each. 



DISEASES OP THE AIR TUBES. 291 



ARTICLE I. 



LESIONS OF CIRCULATION. 



The mucous membrane of the air-passages is frequently af- 
fected with hypersemia, the anatomical characters of which in 
many respects resemble those belonging to hypersemia of the 
gastro-intestinal mucous membrane. 

Hyperaemia of the larynx, trachea, and large bronchial tubes, 
is generally connected with some irritation of those parts; but, 
in the minuter divisions of the bronchia, it is frequently pro- 
duced by a mechanical stagnation and accumulation of the 
blood. This passive congestion of the mucous membrane 
sometimes occurs after death, from the gravitation of the blood ; 
sometimes, during the last moments of life, or even at an earlier 
period in debilitated persons, in whom the force of the circula- 
tion is much weakened ; and in some cases, it is caused by a 
mechanical obstacle to the free return of the blood to the left 
side of the heart. 

It is necessary to distinguish these different species of hy- 
persemia from the red or brown colour which is readily pro- 
duced by putrefaction : and it is also important to recollect, that 
in the smaller bronchia, whose parietes are thin and transparent, 
the red colour of the subjacent parts may easily be mistaken 
for a hyperaemia of the mucous membrane. 

Hypersemia of the mucous membrane lining the air passages 
may be either general or partial. 

General hyperaemia is sometimes formed quite suddenly, and 
gives rise to all the distressing symptoms of asphyxia. Several 
cases have been recorded of persons who, without any apparent 
cause, were suddenly seized with great difficulty of breathing, 
which went on progressively increasing until it terminated in 
death ; and, on dissection, the only morbid appearance was a 
decided redness of the mucous membrane lining the air passages 



292 DISEASES OF THE AIR TUBES. 

throughout its whole extent. Indeed, I can see no reason why 
a simple congestion should not prove fatal in the lungs as well 
as in the brain. We must not, however, forget that the cause 
of these congestions is still unknown; and that the symptoms 
and fatal consequences which generally attend on them, are 
sometimes observed in cases where, on dissection, there is not 
the slightest appearance of congestion to be discovered. 

Universal congestion of the air passages generally assumes a 
less acute form than in the preceding case, and its symptoms 
are proportionally less formidable. The measles are accom- 
panied by a hyperaemia of this subacute form ; and one of the 
lesions most constantly observed in continued fevers, is in like 
manner a general congestion of the mucous membrane of the 
bronchial tubes, which in measles extends to the larynx and 
trachea also. 

General hyperaemia of the mucous membrane of the air 
passages seldom exists in a chronic form. 

The partial hyperaemia of this membrane is a much more 
common affection. It presents the following varieties, which 
are important to be acquainted with, as they each give rise to 
a different train of symptoms. 

1. The larynx and trachea may be red, while the bronchia 
are perfectly pale, and vice versa. In the trachea we some- 
times observe a curious disposition of the hyperaemia; the red- 
ness is confined exclusively to one side, and ceases suddenly at 
the median line, like those erysipelatous affections which attack 
one side of the face exclusively. I have repeatedly observed 
this form of congestion in cases where only one lung was af- 
fected ; and the redness of the trachea was always on the side 
corresponding to the affected lung. 

2. The large bronchia may be red, and the smaller pale. 

3. The small bronchia may be congested, while those of 
larger caliber present no trace of congestion. Congestion of 
the small bronchia gives rise to very formidable symptoms, 
such as violent dyspnoea, fever, &c: in some cases these 
symptoms are attended with little or no cough. 

* 4. On comparing together the bronchia of the different lobes 
with respect to their liability to irritation and congestion, 



DISEASES OF THE AIR TUBES. 293 

M. Broussais was led to conclude that the bronchia of the upper 
lobes are those most frequently affected with hyperemia. 

Hypersemia of the lining membrane of the air passages is not 
necessarily connected with any of the diseases of the paren- 
chymatous substance of the lungs: indeed, it is not very uncom- 
mon to find the trachea and even the bronchia perfectly pale in 
acute pneumonia ; and this is still more common when the 
pneumonia is chronic. It often happens that not the least 
trace of redness is perceptible in the bronchia, when the sub- 
stance of the lung is crowded with tubercles ; in other cases 
the smaller bronchia are more or less red, but the large ones 
and the trachea retain their natural paleness. It is much more 
rare to find the bronchia exempt from redness, when the tuber- 
cles are softened or converted into cavities. In such cases, 
the hyperemia is always most marked in those bronchia which 
are nearest the tubercular excavations; but those which are 
more distant may likewise participate in the redness, which 
sometimes extends to the trachea or even to the larynx. In 
the various cases above mentioned, the hyperaemia sometimes 
proceeds from without inwards, commencing at the larynx, 
spreading successively to the trachea, large bronchia, and small 
bronchia, and at length reaching the pulmonary parenchyma; 
and sometimes it pursues the opposite course, commencing at 
the ultimate divisions of the bronchia, and passing with greater 
or less rapidity to the larger bronchia, trachea, and larynx. 



ARTICLE II. 



LESIONS OF NUTRITION. 



The most remarkable of these lesions, both on account of 
the peculiar symptoms it produces, and the accidents it occa- 
sions, is the increased thickness of the lining membrane. 



294 DISEASES OP THE AIR TUBES. 

There are two species of thickening of the mucous membrane 
of the air passages : the first depends chiefly on the membrane 
being in a state of congestion ; the second is produced by a 
preternatural degree of activity in the nutrition of the mem- 
branous tissue, constituting the true thickening by hypertrophy. 

The first species of thickening may occur at any point of the 
mucous membrane, but is most constantly observed in the 
larynx, and in the small bronchial tubes. 

The tumefaction of that part of the mucous membrane which 
lines the margin of the glottis is sometimes so considerable, 
especially in children, in whom the aperture is particularly 
small, as to block it up almost completely, and consequently to 
oppose the free passage of the air into the lungs, and so pro- 
duce all the symptoms of croup except the membraniform ex- 
pectoration. I am disposed to think, that this form of croup is, 
at the least, as common as that which depends on the forma- 
tion of false membranes ; and it certainly accounts more satis- 
factorily for the peculiar croupy symptoms, the great dyspnoea, 
the peculiar ringing sound of the voice and cough, and the no 
less peculiar sound which the column of air makes in its passage 
through the larynx. 

The mucous membrane of the small bronchia is likewise 
liable to acute attacks of tumefaction from congestion; the 
effect of which is to obstruct more or less perfectly the air tubes 
of a certain number of lobules, and consequently to produce a 
degree of dyspnoea proportionate to its extent. 

The thickening of the laryngo-bronchial membrane by the 
hypertrophy of its tissue is of frequent occurrence in persons 
afflicted with cough of long standing : it may occur in different 
situations, which merit attention on account of the different 
phenomena they occasion. In the larynx, the thickening may 
extend over the whole of its surface, or be limited, 1. to the 
entrance of the glottis; 2. to the cordae vocales; 3. to the ven- 
tricles; or, 4. to the epiglottis. In the trachea, this hypertro- 
phy of the mucous membrane presents nothing peculiar; but, 
in the bronchia, it is important to distinguish whether it occu- 
pies the larger or the smaller tubes. 



DISEASES OF THE AIR TUBES. 295 

I have endeavoured in another work* to prove that a great 
number of the infinite varieties of bronchial rattle depend on 
the various degrees of thickening of the mucous membrane : 
in fact, the slightest alteration in the thickness of this membrane 
frequently produces the most remarkable modifications in the 
sound of the pulmonary expansion ; so that in general there is 
no proportion whatever, in these cases, between the alteration 
of sound and the alteration of texture. 

The effects of hypertrophy are not confined to increasing 
the number of the molecules of which the mucous membrane 
is in the natural state composed: it may likewise change the 
mode of arrangement of those molecules, and transform the 
affected tissue into another, according to the laws laid down in 
the first volume ; or without producing this transformation, it 
may render the organization of the part more complicated 
than natural. M. Reynaud found a remarkable example of 
this effect of hypertrophy in an individual who had for many 
years previously laboured under chronic cough ; the bronchial 
mucous membrane had become perfectly similar to that of the 
intestines, and like it was studded over with a number of villous 
eminences. 

Hypertrophy of the mucous membrane of the air tubes may 
present itself in other forms besides those already described ; 
thus, it may be confined to a circumscribed point, and produce 
there a tumour projecting more or less above the level of the 
surrounding membrane. These tumours have been oftener 
observed in the larynx than in any other part of the air pas- 
sages. I recollect having seen a larynx some years back, at 
La Charite, the superior aperture of which was almost com- 
pletely obstructed by a whitish cauliflower vegetation, which 
was evidently continuous by a broad basis with the mucous 
membrane. M. Ferrus recently exhibited a specimen al- 
most precisely similar, to the Academic Royale de Medi- 
cine. 

There is yet another form of this hypertrophy, namely, its 
being confined to the follicles with which the mucous mem- 



Clinique Mtdicale. 



296 DISEASES OF THE AIR TUBES. 

brane of the air tubes is so thickly studded. In such cases the 
internal surface of the membrane presents a number of round 
granular bodies, either white, or of a red, or dark brown 
colour, which are often surrounded by two coloured circles, 
one, round the centre, the other, round the base. This altera- 
tion of the follicles has often been mistaken for tubercles, or 
the variolous eruption. 

No doubt, atrophy of the mucous membrane of the air pas- 
sages occurs sometimes ; but it has not as yet been described. 
It is frequently found in a state of softening, which, however, 
presents no peculiar character ; so that the description given of 
the softening of the mucous membrane of the intestines is 
equally applicable here. This affection has been principally 
observed in the larynx, especially in the cordse vocales, and at 
the bottom of the ventricles. When it attacks this portion of 
the mucous membrane, the bright fibres of the thyro-arytenoid 
ligament appear almost completely bare, or if covered, it is 
only by a few spots of a reddish pulpy substance. I have 
more than once been surprised to find no other lesion in the 
larynx than this softening of its mucous membrane, in individ- 
uals whose voice had been for a length of time either hoarse or 
altogether extinct. 

The mucous membrane of the air tubes is likewise liable to 
ulceration ; the ulcers may be situated either in the larynx, 
trachea, or bronchia. Ulcers of the larynx are more common 
than those of the trachea, or bronchia ; but, as it seldom or 
never happens that we find ulcers in the larynx, on dissection, 
without at the same time finding them also in the parenchyma 
of the lung, we can scarcely form a correct idea of their effect 
on the general health. The disease which has been designated 
phthisis laryngea is, in most cases, nothing more than a pulmo- 
nary affection, accompanied by a morbid condition of the larynx, 
the symptoms of which predominate and mask the others, 
though in reality it is chiefly on the affection of the lungs that 
the emaciation, hectic fever, night-sweats, and other symptoms 
of phthisis depend. 

Ulcers are found in different parts of the larynx, and, accord- 
ing to the situation they occupy, produce different modifica- 



DISEASES OF THE AIR TUBES. 297 

tions in the voice. They may be situated on, I. the epiglottis ; 
2. the cordse vocales ; 3. the ventricles ; 4. the angle formed 
anteriorly by the union of the two sides of the thyroid ; and, 
5. the mucous membrane situated between the arytenoid car- 
tilages ; in short, they are found in every point of the internal 
surface of the larynx, though it sometimes requires a minute 
examination to discover them. 

Ulcers of the larynx vary considerably in size and number. 
Sometimes, only one small ulcer is to be found in a larynx 
which in every other respect appears perfectly healthy ; some- 
times the internal surface of the larynx is literally eaten away 
with ulcers of different forms and sizes ; and in some cases, 
again, there is only one large ulcer to be found spreading over 
one-half or more of the larynx. 

Ulcers of the trachea occur more frequently on its posterior 
surface, than in any other part of its circumference ; and as 
they are almost exclusively confined to phthisical cases, it was 
supposed that they are caused by the frequent contact of the 
sputa : however, proofs are still wanting to confirm this suppo- 
sition. In some cases these ulcers are exclusively confined ^o 
one side of the trachea, which invariably corresponds to the 
diseased lung, or, if both lungs be diseased, to that which is 
most affected. 

In the bronchia, ulcers are not so common as in the larynx, 
but more so than in the trachea. There is nothing peculi.ar in 
their appearance or which merits a particular description : be- 
sides, they are so uncommon that we may make a great num- 
ber of dissections without once meeting them. 

The ulcers of the mucous membrane lining the air passages 
generally have their bottom formed by the subjacent tissues. 
Sometimes the delicate layer of cellular tissue interposed be- 
tween the mucous and the other tissues is much thickened, 
and forms their bottom ; but, in other cases, they burrow still 
deeper, and the subjacent tissues are one after another de- 
stroyed, until the walls of the air tube are at length bored 
through. This perforation produces different phenomena, ac- 
cording to the situation where it occurs. Thus, it sometimes 
produces a direct communication between the interior of the 

Vol. II. 39 



298 DISEASES OF THE AIR TUBES. 

tube and the external atmosphere, as in cases of fistula situated 
in the anterior angle of the thyroid. I may remark, en passant, 
that the existence of such a fistulous communication does not 
incapacitate the individual from making a considerable effort, 
as M. Bourdon's theory would necessarily infer. In proof of 
this assertion, I may adduce from Beclard, the case of a horse 
affected with that disease, which, in veterinary language, con- 
stitutes a roarer : this animal had an opening made in the tra- 
chea, through which he breathed exclusively, and in this state 
was seen by Beclard drawing a heavily laden waggon. 

In other cases, the perforation of the air tube causes a com- 
munication between it and some neighbouring organ, either 
• naturally hollow, as the oesophagus, aorta, &c, or rendered 
hollow by disease, such as the bronchial glands when excava- 
ted, or the parenchyma of the lungs. In the great majority of 
cases, the excavation of the lung undoubtedly precedes the 
perforation of the bronchial tube which is at a later period of 
the disease found communicating with it ; but I am inclined to 
think that the ulceration and perforation of the bronchial tube 
occasionally precedes and gives rise to the formation of the 
pulmonary abscess. At the present day, it is the fashion to at- 
tribute almost every cavity that is found in the lungs, to the 
liquefaction of a mass of tubercles ; but this explanation is in 
many cases a mere assumption totally devoid of proof. 

In the preceding paragraph, we have seen an instance of the 
air tubes being perforated from without inwards, the disease 
commencing in the lungs, and passing successively through the 
coats of the bronchion to its inner membrane ; but this is not 
the only case in which the perforation is thus effected. The 
aorta much more frequently bursts into the trachea or bronchia, 
than these tubes do into it ; and in those cases where the oeso- 
phagus and trachea communicate, the perforation as often be- 
gins in the former as in the latter. Suppuration of the bron- 
chial ganglions seems frequently to cause the perforation of the 
bronchia which they immediately surround, and by means of 
this perforation they discharge the morbid matter secreted in 
their interior. I once saw a case, where a large abscess of the 
thyroid gland produced the total destruction of the fibrous and 



DISEASES OP THE AIR TUBES. 299 

cartilaginous tissues of the trachea, so that the pus contained in 
the abscess was only prevented from escaping into it by its 
mucous membrane, which had not as yet participated in the 
disease, though I think it highly probable it would have done 
so, had the individual lived for any time longer. M. Portal, in 
his Traite de la Phthisie Pidmonaire, relates a case of perfora- 
tion of the trachea, which afforded a passage to a number of hy- 
datids that were formed in the thyroid gland. The patient 
died suddenly of asphyxia. 



ARTICLE III. 



LESIONS OF SECRETION. 



These morbid alterations may occur, 1. in the gaseous se- 
cretion ; 2. in the perspiratory exhalation ; and, 3. in the mu- 
cous secretion. 

The alterations of the gaseous secretion are as yet but little 
understood. It is, however, reasonable to suppose that, in cer- 
tain diseases, there must be some alteration in the proportions 
of the different gases naturally exhaled by the mucous mem- 
brane of the lungs. This supposition is the more probable, as 
it is now well ascertained that other conditions, such as those of 
age and external temperature, produce considerable variations 
in the proportionate quantity of azote which issues from the 
lungs at each expiration. 

The alterations of the perspiratory secretion are scarcely 
better known than those of the gaseous exhalation. Perhaps 
its increase gives rise to some of those serous fluxes that occa- 
sionally take place from the mucous membrane of the lungs, 
and that in this way the serous exhalation which usually issues 
from the lungs in a state of vapour, is by its excessive quantity 



300 DISEASES OF THE AIR TUBES. 

condensed into the liquid form. In my Clinique Medicde, I 
have related the case of an individual who suddenly discharged 
an enormons quantity of serous fluid by the bronchia, at the 
same time that the fluid of a hydrothorax under which he had 
previously laboured was absorbed. It has been alleged that, 
in certain diseases of the skin where the cutaneous transpiration 
was wholly suppressed, the pulmonary vapour was so greatly 
increased, that it was seen issuing from the thorax in clouds, 
which rose to the roof of the bedstead, from whence they again 
descended in the form of an abundant dew.* 

The mucous secretion has been more successfully studied, 

and is consequently better known, than either of the preceding. 

The mucus secreted by the mucous membrane of the larynx 

and bronchia, may be modified either in its quantity, or in its 

qualities. 

Its increase of quantity may be either an acute or a chronic 
affection. It would be inconsistent with the plan of this work 
to describe the different appearances of mucous expectoration, 
as the consideration of this subject properly belongs to works 
on semeiology. To these therefore, I refer the reader, for a 
detailed account of the numerous varieties which this secretion 
presents in different diseases ; and shall for the present confine 
my remarks to those cases where the mucus is found in the 
bronchia after death, and from its situation affords some expla- 
nation of the symptoms observed during life, or even of the fatal 
termination which ensued. The most remarkable case of this 
description is that in which such an enormous quantity of mu- 
cus is suddenly secreted by the bronchia, trachea, and larynx, 
that their cavity is completely filled, and consequently, as the 
air has no longer access to the lungs, death from asphyxia imme- 
diately follows. This immoderate secretion of mucus has been 
observed in adults, but it is most common in children. M. Blaud, 
in a work lately published, has described as a peculiar species 
of croup, several cases which presented many of the character- 
istic symptoms of that disease ; while, on dissection, the only 



* Alibcit. Precis des Maladies de la Peau, article Ichthyose. 



DISEASES OF THE AIK TUBES. 301 

morbid appearance consisted of an excessive accumulation of 
mucus throughout the whole of the air tubes.* 

Without entering on the province of the semeiologist, I may 
remark that the mucous furnished by the laryngo-bronchial 
membrane sometimes becomes so fluid as to resemble serum, 
and sometimes acquires such a degree of viscidity that it ad- 
heres to the sides of the bronchia, and by its accumulation forms 
a kind of plug or stopper which effectually prevents the pas- 
sage of the air, and thus produces a violent or even fatal dysp- 
noea; as in a case of which I have detailed particulars in my 
Clinique Medicate. In the cases hitherto enumerated, the sen- 
sible qualities of the secretion were not so changed, but that 
its mucous character might still be recognized ; but there are 
also cases, in which it gradually loses all its characteristic 
qualities, and is at last transformed into a fluid altogether dif- 
ferent from mucus. Thus, instead of mucus, we sometimes 
find in the bronchial tube a fluid presenting all the characters 
of pus, and that too in cases where there is not the least ap- 
pearance of ulceration in the bronchial membrane. There are 
likewise on record several well authenticated cases of puriform 
expectoration going on constantly for a length of time before 
death, although, on dissection, the mucous membrane presented 
no perceptible lesion, not even a blush of redness. In these 
cases we have an example of an alteration of the fluid secret- 
ed independent of any visible alteration in the secreting mem- 
brane. 

Lastly, the air passages are sometimes, more frequently in- 
deed than any other mucous cavity, lined with membraniform 
concretions. These concretions or false membranes, as they 
are generally called, have by some authors been considered as 
the product of the highest possible degree of irritation of the 



* M. Blaud has well remarked, that the word croup should rather be employ- 
ed to designate a certain train of symptoms, than a single anatomical lesion ; 
and he accordingly establishes three varieties of this disease, founded on the na- 
ture of the morbid products furnished by the irritated membrane. The variety 
described in the text he denominates croup myxagene, and the other two, croup 
puogene, and croup meningogene. 



302 DISEASES OF THE AIR TUBES. 

mucous membrane ; this opinion, if adopted, would so materially 
influence our practice, that it may be worth while to exam- 
ine carefully and dispassionately, the arguments which may be 
urged in its favour. In the first place, it is certain that the for- 
mation of false membranes may be readily produced by intro- 
ducing into the air passages any highly irritating substance, 
such as alcohol, dilute sulphuric acid, oil of turpentine, &c. ; 
they have likewise been produced by inspiring chlorine or am- 
monia for any length of time; but these results do not constantly 
follow : the action of these irritants on the mucous membrane 
of the trachea or larynx does not in every case determine the 
formation of a false membrane, consequently there must be a 
predisposition on the part of the individual. But if this pre- 
disposition be very strong, it is evident, that the action of much 
less irritating substances than any of those above mentioned, 
nay, the slightest degree of irritation, will be sufficient to de- 
termine the formation of false membranes in the larynx, tra- 
chea, and bronchia: whereas, if there be no predisposition to 
the disease, the highest degree of artificial irritation that we can 
excite, or the most intense inflammation developed of its own 
accord, will not be sufficient to cause the formation of a single 
false membrane. 

Hence I think it is evident that the formation of false mem- 
branes in the air passages cannot be accounted for solely by the 
intensity of the irritation which preceded their developement. 
Is it because children are subject to more violent irritation of 
the air passages than adults, that the formation of false mem- 
branes is so much more common at that period of life? Cer- 
tainly not ; but rather because there is in children a peculiar 
state or disposition of the constitution, which causes any irrita- 
tion that occurs to present a certain train of symptoms, follow 
a certain course, and terminate in a certain manner. Is it be- 
cause two blisters create different degrees of irritation, that one 
causes a secretion of pus, while the other produces a thick 
layer of a substance like hog's lard all over the blistered sur- 
face? Such an opinion is merely hypothetical ; whereas all 
practitioners are well aware that the difference of the secretion 
coincides more frequently with certain general conditions of 



DISEASES OF THE AIR TUBES. 303 

the economy, which experience teaches us to recognize, than 
with any determinate degree of irritation in the blistered sur- 
face. In some children the cause which influences the for- 
mation of these false membranes in the air passages is evidently 
general or constitutional, inasmuch as they are often formed at 
the same time in the nasal fossae, in the alimentary canal, 
around the anus, in the external meatus auditorius, and wher- 
ever the skin has undergone the slightest solution of continuity. 
Within these last few years, much importance has been 
deservedly attached to the local irritation which precedes or 
accompanies the developement of these false membranes; but, 
whilst endeavouring to combat this irritation, we should never 
forget that a principal cause of their formation is to be found 
in the state of the general health, and consequently that, in 
treating these affections, copious blood-letting is not in every 
case the only indication to be fulfilled : the abstraction of blood 
is, within certain limits, of infinite utility in subduing the local 
affection, but, when carried to excess, it may favour that state 
of the system, of which the local affection is often merely the 
effect. 

The false membranes of the air passages vary considerably 
in thickness, and in consistence. Some are so delicate as to 
be nearly transparent, while others are several lines in thick- 
ness. Nor is their consistence • less variable, for some can 
scarcely be touched without falling to pieces, while others may 
be detached whole and entire, and even bear to be taken up 
in the hand and examined. 

Schwilgue analyzed these membranes, and found them com- 
posed of albumen united to a certain proportion of carbonate 
of soda and of phosphate of lime ; Bretonneau states that he 
detected some fibrine in them. 

The false membranes of the air passages in general present 
no trace of organization ; some authors, however, affirm that 
they have observed vessels passing in the form of filaments 
from the concretion to the subjacent membrane. We must 
not mistake for the result of organization those filaments which 
occasionally unite the false membrane to the mucous mem- 
brane underneath, as these are merely prolongations of the 



304 DISEASES OF THE AIR TUBES. 

false membrane dipping into the mucous follicles; neither 
should we be deceived by the red spots which are sometimes 
scattered over its surface, as they are in almost every instance 
caused by haemorrhage from the subjacent mucous membrane. 
I shall not now stop to examine the cases which have been ad- 
duced to establish the fact of the organization of these false 
membranes, as they are yet insufficient for that purpose : in 
theory, however, I see no objection to the possibility of their 
organization. 

There are four principal divisions of the air tube in which 
these membranous concretions may occur: 1. in the larynx; 
2. in the trachea; 3. in the large bronchia ; and, 4. in those of 
small caliber. In each of these divisions, they may exist in 
the form of isolated patches, or of one continuous layer. In 
some cases, these concretions occupy simultaneously the whole 
extent of the air passages; in others, they begin at the larynx, and 
extend more or less rapidly to the ultimate divisions of the 
bronchial tubes, or vice versa. In some instances, they are 
first formed out of the air passages, and only make their appear- 
ance there, after having successively attacked the nasal fossae, 
the mouth, the soft palate, and the pharynx. 

I have already stated that the formation of false membranes 
in the air passages occurs most frequently in children ; but, 
even in childhood, some ages are more subject to this affection 
than others. It very seldom occurs before the end of the 
second year, although there is at this period of life a remarka- 
ble disposition to the formation of false membranes on other 
mucous surfaces, especially in the nasal fossae, mouth, pharynx, 
and oesophagus. Why is it, that these membranes so seldom 
extend to the larynx at this age, and have such a tendency to 
do so afterwards ? 

The formation of false membranes in the air passages is most 
commonly an acute disease: sometimes, however, it maybe 
termed a chronic affection, as well from the length of its du- 
ration, as from the nature of the symptoms which attend it. In 
children it may assume a chronic character, so long as the 
membraniform exudation is confined to the trachea; and in 
adults it sometimes appears as a chronic disease, even when it 



DISEASES OF THE AIR TUBES. 305 

affects the larynx. Except in those cases where the false mem- 
brane is of considerable thickness, the dyspnoea which accom- 
panies it is not so much caused by its presence, as by the 
tumefaction of the subjacent membrane, and, not unfrequently, 
by the spasmodic contraction of the muscles of the larynx. 
False membranes, however, do occasionally produce suffoca- 
tion by their presence; more especially when they are seated 
in the last ramifications of the bronchia, where they are inter- 
posed between the air and the blood, and so prevent their 
mutual action on each other. 

The formation of membraniform concretions is not a disease 
peculiar to man ; the Journal de Medecine Veterinaire for the 
year 1825, gives an account of a cow, that made a noise on 
inspiration like that made by horses called roarers ; this was 
attended with a convulsive cough, which appeared to proceed 
from the presence of some foreign body in the trachea. The 
animal died, and on dissection the internal surface of the larynx 
was found lined by a thick layer of false membrane. The 
same appearances have likewise been found in horses. 

Laennec once found in one of the bronchial tubes of a 
phthisical patient a concretion that almost filled its cavity, 
leaving scarcely the breadth of half a line between itself and 
the sides of the bronchion. The concretion differed in its na- 
ture as well as appearance, from the ordinary false membranes, 
and rather resembled the polypous concretions which are found 
in the heart and arteries ; Laennec's idea of its origin was, that 
it was merely a coagulum of blood arrested in the bronchion 
during an attack of haemoptysis. 

Another class of concretions very different from the preced- 
ing, both in appearance and chemical composition, are some- 
times found in the air passages. The concretions to which I 
now allude are essentially composed of phosphate of lime, and 
are generally known by the name of calculous concretions. 
They are formed either in the substance of the lungs, whence 
they escape into the bronchia, or in the air tubes themselves ; 
and may occur, 1. in the minute ramifications of the bronchia, 
the branched form of which they sometimes represent exactly ; 

Vol. II. 40 



306 DISEASES OF THE AIR TUBES. 

2. in the bronchia of larger caliber ; 3. in the larynx, where 
they have sometimes been found impacted in the ventricles. 

The cause which produces the formation of calculi in the 
bronchia is no better understood than that which promotes 
their developement in other parts of the body ; but this much 
at least is certain, that their production cannot be accounted 
for by irritation. 

Hydatids have also been found in the air passages ; in some 
cases, they are developed in those passages, and in others they 
are originally formed either in the pulmonary parenchyma, 
pleura, liver, thyroid gland, or some other contiguous organ, 
and subsequently burst into the air tubes. A hydatid, devel- 
oped in one of the ventricles of the larynx, has been known to 
project so into the cavity, as to give rise to all the symptoms 
which usually attend the presence of a foreign body there. 

The mucous membrane of the air passages sometimes allows 
the blood to escape from its vessels ; a certain proportion of 
cases of haemoptysis arise in this way ; for, on dissection, it 
not unfrequently happens that no morbid appearance is found 
in the lungs of persons dying of haemoptysis, except in the 
mucous membrane, and even there the alteration amounts 
merely to a slight redness. 

When the haemorrhage takes place in the minute bronchial 
ramifications, a part of the blood which is exhaled sometimes 
collects and coagulates there, and so imparts a black or brown 
colour to the lobules in which the coagulation takes place: 
such is, I conceive, the usual origin of the morbid appearance 
to which Laennec has given the name of pulmonary apoplexy. 
This lesion is characterized by the lung presenting one or more 
circumscribed, indurated masses, of a dark brown or black 
colour, and is seldom found except in persons who have died 
during an attack of hemoptysis ; I have, however, occasionally 
seen it in the lungs of individuals who never had spit up any 
blood. It is decidedly most common in those cases of hemop- 
tysis which occur during the course of organic disease of the 
heart. In no case, however, can the morbid appearance term- 
ed pulmonary apoplexy be regarded as the source of the hae- 
moptysis : it is, in fact, a mere accidental lesion, produced by the 



DISEASES OF THE AIR. TUBES. 307 

stasis and coagulation of the blood in a certain number of the 
small ramifications of the bronchia, while the haemorrhage pro- 
ceeds from a much larger extent of the mucous surface. There 
is another species of haemorrhage which is seated in the paren- 
chymatous structure of the lung, to which the name of pulmo- 
nary apoplexy might with more propriety be applied ; but I 
shall defer the further consideration of this subject until I come 
to speak of the diseases of the parenchyma of the lungs. 



CHAPTER II. 



Lesions of the Tissues subjacent to the Mucous Membrane. 

The cartilaginous tissue which enters as an anatomical in- 
gredient into the composition of the air tubes, is most subject 
to disease in that portion of its extent where it is most devel- 
oped, namely, in the larynx. The cartilage of the epiglottis is 
not unfrequently the seat of disease, in consequence of which 
it sometimes loses its natural form ;~but this alteration is more 
generally caused by the thickening of its mucous coat, or of its 
submucous cellular membrane, than by any alteration in its 
cartilaginous tissue. Ossification of the epiglottis is exceeding- 
ly rare ; but a minor degree of induration is by no means un- 
common, the effect of which is to render it less moveable, so 
that it is with difficulty bent down to protect the aperture of 
the larynx. Sometimes there is scarcely a vestige of the epi- 
glottis to be found, in consequence of its having been almost en- 
tirely destroyed by ulceration originally commencing either in 
its own tissue, or in the mucous membrane which envelopes 
it. 

The other cartilages of the larynx present nearly the same 
morbid alteration as the epiglottis. Of these, the most com- 



308 DISEASES OF THE AIR TUBES. 

mon is ulceration, which, when superficial, renders their sur- 
face rugged and uneven, and, when it extends farther, causes a 
more or less extensive destruction of the part. Sometimes the 
ulcerative process begins in the soft parts, and from thence 
passes to the cartilaginous tissue ; in other cases the ulceration 
commences in the cartilage, and purulent matter is in conse- 
quence collected in front of the ulcerating cartilage, until a 
fistulous passage is formed for its escape : in general, the fis- 
tula opens on the mucous surface in the interior of the larynx, 
but in some instances it opens externally. The ulceration 
sometimes commences in the articulations of the different 
cartilages : in this case, the articulation is found filled with pus, 
the ligaments are destroyed, and the articulating surfaces more 
or less injured. 

Ossification of the thyroid and cricoid cartilages occurs as a 
natural phenomenon in old age ; but, at an earlier period of 
life, it constitutes a true morbid state. I am not aware that the 
arytenoid cartilages have ever been found ossified. 

The cartilaginous rings of the trachea are very seldom dis- 
eased, ossification being almost the only morbid alteration to 
which they are subject. 

The cartilaginous tissue of the bronchia is, on the contrary, 

frequently altered from its healthy structure. In the first 

place, it is often affected with hypertrophy, and then not only 

becomes more apparent than in the natural state, but likewise 

changes its form and arrangement ; so that where it generally 

appears in minute grains, we now find it forming segments of 

circles as in the large bronchia, and in the trachea. It 

also sometimes becomes ossified, so as to form masses 

which feel like calculi imbedded in the parietes of the 

bronchia. The following is an example of a much rarer 

species of ossification. On dissecting the body of an old man, 

M. Reynaud and I found the lungs full of hard masses, which, 

unlike the ordinary calcareous concretions, were composed of 

an infinite number of osseous spicuhe, arranged like the branches 

of a tree, and containing a continuous cavity in their interior, 

so small as barely to admit a hair. We both agreed that these 



DISEASES OF THE AIR TUBES. 309 

arborescent concretions were in fact the ultimate ramifications 
of the bronchia converted into bone.* 

Another morbid condition of the bronchial cartilages which 
deserves to be noticed, is a peculiar brittleness, in consequence 
of which they break into fragments that either project into the 
cavity of the bronchia, or become altogether detached, and re- 
main loose in the bronchia, until they are expectorated. 

The fibrous tissue which enters into the composition of the 
parietes of the air passages presents only two species of mor- 
bid alteration worthy of notice, namely, softening and hyper- 
trophy. When the thyro-arytenoid ligament is softened, the 
voice is altered in a most remarkable manner. The anatom- 
ical characters of the softening of this ligament are the follow- 
ing: it loses its brilliant colour, becomes opaque and dull, and is 
subsequently resolved into cellular tissue, or into an unorganiz- 
ed pulpy substance, which in its turn disappears, leaving the 
thyro-arytenoid muscle naked and exposed. 

The fibrous tissue is also liable to hypertrophy, the conse- 
quence of which is, an evident increase in the thickness of the 
part into which it enters as an alimentary ingredient. 

The muscular tissue, which, in some animals is so well devel- 
oped in the larynx, trachea, and primary divisions of the bron- 
chia, is scarcely perceptible in man except in the larynx, and 
some points of the trachea. As a morbid condition, however, 
I have in some instances detected it in the parietes of the hu- 
man bronchia, in which I believe it always exists in a rudiment- 
ary state, though it is only visible when preternaturally devel- 
oped by the effects of disease. 

In the larynx, where the muscular tissue is arranged in dis- 
tinct faciculi, it presents certain morbid alterations which de- 
serve to be ranked among some of the most serious diseases to 
which this organ is liable. The principal of these alterations 



* I have since had an opportunity of examining the lungs of an old woman of 
86, which were studded with a great number of cartilaginous and osseous concre- 
tions, which were evidently produced by the transformation of the parietes of 
the last ramifications of the bronchia into cartilaginous and osseous tissue. 



310 DISEASES OF THE AIR TUBES. 

are the following: the muscles become softened, are reduced 
to a state of atrophy, or even completely destroyed,; and in other 
cases they are found infiltrated with pus, mucus, or tubercu- 
lous matter. I have more than once found, on examining the 
larynx of individuals who had during life completely lost their 
voice, that the only morbid appearance which could be detect- 
ed to account for the aphonia, was seated in the thyro-aryte- 
noid muscle, the fibres of which were in some instances re- 
duced to a remarkable state of atrophy, and in others, infil- 
trated by different morbid secretions, such as pus, tubercle, &c. 

Much importance was formerly attached to the varicose dila- 
tation of the veins of the air passages, and several cases of 
haemoptysis were suposed to originate from this source: though 
my experience has been tolerably extensive, I have never yet 
found an instance of the morbid appearance in question. 

Tumours of different kinds occasionally compress the nerves 
which are distributed to the parietes of the bronchia, and thus 
give rise to the same symptoms that would result if those 
parietes themselves were affected. 

We have now enumerated the different tissues of which the 
air tubes are composed, and described the morbid alterations 
to which they are severally liable : the cellular membrane that 
serves to unite these tissues together is likewise subject to a 
variety of morbid alterations which next claim our attention. 
In the larynx, the cellular tissue is not unfrequently affected 
with hypersemia ; it is likewise subject to hypertrophy, be- 
comes thickened, indurated, and presents the appearance of 
scirrhus ; by its increased thickness it diminishes the caliber of 
the larynx, impedes the action of the muscles, and alters the 
form and movements of the epiglottis. Serous infiltration is 
another affection to which this portion of the cellular tissue is 
subject : indeed, oedema of the glottis, so well described by 
Bayle, is nothing more than a considerable infiltration of the 
cellular tissue situated between the folds of mucous membrane 
which surround the rima of the glottis, and which, from being 
thus distended and swoln, obstruct the passage of the larynx to 
a greater or less degree. This oedema rarely occurs as an 
idiopathic disease ; it is most commonly connected with acute 



DISEASES OF THE AIK TUBES. 311 

inflammation of the mucous membrane of the larynx, though it 
sometimes occurs during the progress of chronic affections of 
that organ. It is in some cases very slow in its formation, and 
does not materially affect the respiration ; in others, it com- 
mences suddenly, runs its course rapidly, and quickly ter- 
minates in asphyxia and death. 

Pus is another morbid secretion occasionally found in the 
cellular tissue of the air tubes, either collected in the form of 
abscess, or infiltrating the tissue to a greater or less extent. I 
recollect a case in which one of the ventricles of the larynx 
was occupied by a fluctuating tumour which, on a slight incision 
being made into it, gave out a copious discharge of pus. The 
last morbid production which I shall enumerate is tuberculous 
matter; it is most frequently found in the walls of the larynx, 
in the form of small isolated masses. I once found in an in- 
fant a remarkable example of the secretion of tuberculous 
matter in the cellular tissue connecting the principal bronchia 
to the parenchyma of the lung ; the parietes of the bronchia 
were in fact coated with a layer of it several lines thick: there 
were no tubercles in any other part of the lung. The infant 
died in the hooping cough. 



CHAPTER III. 



Alterations in the Dimensions of the Air Tubes. 

The several morbid alterations which we have enumerated 
as occurring in the different tissues that enter into the composi- 
tion of the larynx, trachea, and bronchia, not unfrequently lead 
to an alteration in the dimensions of these tubes ; this altera- 
tion may consist either in an increase or diminution of their 
natural caliber. 



312 DISEASES OF THE A.IR TUBES. 

The diminished capacity of the air tubes is in general pro- 
duced by some of the following causes : 

1. Thickening of the mucous membrane. The contraction 
arising from this cause is in some cases very considerable : it 
occurs chiefly in the glottis and in the small bronchia. 

2. The presence of a false membrane. It seldom happens 
that a false membrane really produces any considerable dim- 
inution in the caliber of the air passages, unless in the small 
bronchia, or in the larynx of children. 

3. Foreign bodies, either introduced from without, or formed 
in the part, such as calculi, hydatids, solidified mucus, coagula 
of blood, or bits of cartilage. 

4. The compression of one of the air passages by a tumour 
situated externally to it. In this way, considerable deformity 
and contraction of the larynx is sometimes produced by the 
preternatural developement of the thyroid gland : the same 
effect may be produced on the trachea or bronchia, by the 
pressure of an aneurismal tumour ; and the bronchia are often 
compressed or even obliterated, at their entry into the lungs, 
by an enlargement of the bronchial ganglions which surround 
them at that point. 

The increased capacity, or dilatation of the air tubes was 
first particularly described by Laennec. It affects principally 
the smaller bronchia, the dilatation of which may readily be 
mistaken for abscesses or tuberculous excavations. 

Dilatation of the bronchia does not always appear in the 
same form. The following are the principal varieties which it 
presents : 

In the first, one or more bronchia appear uniformly dilated 
throughout their whole extent, so that those bronchial ramifica- 
tions which in the natural state would scarcely admit a fine 
probe, attain to the size of a goose quill, or even exceed it, and 
in some instances become so dilated, as to admit the introduc- 
tioii of the finger ; in such cases, we frequently observe a 
moderate sized bronchial tube giving off branches much larger 
than itself. These dilated branches are often visible on the 
surface of the lung, where they terminate in a sort of cul-de- 
sac in the walls of which the orifices of a number of minute 



DISEASES OF THE AIR TUBES. 313 

bronchia are always visible ; not unfrequently, they terminate 
abruptly near the top of the lung, either in a portion of black 
indurated pulmonary parenchyma, in a fibrous or cartilaginous 
mass, or in a calculous concretion, which in some instances 
exists outside the cavity of the bronchion, and in others is con- 
tained within a sort of cul-de-sac, that apparently forms the 
termination of the dilated bronchial tube. 

A second species of dilatation of the bronchia is that in which 
the dilatation is limited to a certain point of the tube ; the por- 
tion of the tube thus dilated presents, at first sight, the appear- 
ance of a circumscribed cavity excavated in the parenchyma- 
tous structure of the lung. This mistake is particularly liable 
to be made, when the dilatation occurs in the upper lobe, where, 
as is well known, tuberculous excavations are generally found; 
the dilataion is still more likely to be mistaken for one of those 
cavities with smooth polished walls, which are in all probabil- 
ity the remains of the favourable termination of tuberculous 
abscess. The size of the cavity formed by this species of local 
dilatation may vary from that of a grain of hemp seed, to that 
of an almond, or even of a walnut. Several bronchia may pre- 
sent this species of dilatation in the same lung; and when they 
are situated close together, they form by their communications 
a sort of complicated sinus filled with puriform mucus, and 
bearing a strong resemblance to those tuberculous excavations 
that consist of a number of loculi or cells communicating to- 
gether. 

The last form of dilatation I shall enumerate is that in which 
one or more bronchial tubes present a series of successive fusi- 
form dilatations between each of which the tube reassumes its 
natural caliber. In the dilated points, the parietes of the tube 
are generally thin and transparent, so that the mucous or puri- 
form fluid which they contain may be seen through them. It 
not unfrequently happens that one lung contains a considerable 
number of these dilatations, which give it, when cut into, the 
appearance of containing a number of small abscesses. I have 
observed this form of dilatation of the bronchia more frequently 
in children than in adults. 

Yol. II. 41 



314 DISEASES OF THE AIR TUBES. 

In the different forms of dilatation just enumerated, the par- 
ietes of the dilated bronchia are variously affected. In some 
cases, they are considerably hypertrophied, and the several 
anatomical elements which enter into their composition become 
more marked, and more fully developed, than in the natural 
state: sometimes, on the contrary, their parietes are reduced 
to a delicate membrane, in which it is impossible to discover 
any trace of either the fibrous or cartilaginous tissue. 

Dilatation of the bronchia is seldom found except in individ- 
uals who have long suffered from attacks of chronic cough. 
One of the cases of this affection recorded by Laennec in his 
treatise on Mediate Auscultation, was that of an old woman, 
who died at the age of seventy-two, after having presented 
most of the symptoms of phthisis from the age of sixteen. On 
dissection, not a single tubercle was to be found in the lungs, 
but they contained a number of cavities, which on close exami- 
nation proved to be dilatations of the bronchia. The largest 
of these cavities was about the size of an almond ; they were 
evidently continuous with the bronchia, which commenced 
dilating near the part where the cartilages disappear from their 
parietes, and gradually increased in size until their determina- 
tion near the surface of the lung. 

The bronchia may, however, become dilated in a much 
shorter space of time ; for they have been found considerably 
dilated' in children who had had the hooping cough during the 
last two or three months of their lives, and who had never had 
any cough previously. 

When the dilatation of the bronchia is not considerable, it 
does not appear to exert any influence on the parenchymatous 
structure of the lung; but when it is very considerable, it com- 
presses and condenses the surrounding parenchyma. Fre- 
quently, also, dilatation of the bronchia coincides with an indu- 
rated condition of the adjacent pulmonary substance, which, at 
the same time, becomes either of a grey or black colour. 



DISEASES OP THE PARENCHYMA, ETC. 315 



SECTION II. 



DISEASES OF THE PARENCHYMA OF THE LUNGS. 



We have already endeavoured to analyse the composition of 
the pulmonary parenchyma, and to reduce it to its anatomical 
elements. We have found it composed of three distinct parts, 
namely, 1. the vesicles or cells in which the last bronchial rami- 
fications terminate ; 2. the parietes of these vesicles, formed by 
a delicate membrane, on which the pulmonary vessels and veins 
ramify in an extreme state of fineness ; and, 3. the cellular tissue 
which serves to unite these parts together. 

All the different diseases to which the lungs are liable must 
necessarily have their seat in one or other of these three parts ; 
and they have in common the important effect of diminishing 
the surface which the blood presents to the action of the air. 
The diminution of this surface may depend on either of two 
conditions, a diminution in the caliber of the air cells, or a dim- 
inution in the number of their parietes. The first of these 
conditions may be produced by a simple hyperemia; the se- 
cond depends on atrophy of the pulmonary tissue. The greater 
number of the symptoms which accompany the diseases of the 
parenchyma of the lungs depend on this diminution of the 
aerating surface. 

If portions of lungs presenting the most different morbid al- 
terations be inflated and dried previous to examination, we then 
perceive pulmonary parenchyma reduced to an assemblage of 
tubes and cells, and can distinguish the morbid alterations 
which have taken place either in the interior of these tubes and 



316 PISE ASKS OF THE 

cells, in their parietes, or in the cellular tissue which unites 
them. These appearances are quite evident in some diseases, 
and may fairly be admitted by analogy in those affections 
which cannot be submitted to this method of examination. 



CHAPTER I. 



LESIONS OF CIRCULATION. 



In the lungs, as in every other organ, the quantity of blood 
which circulates in the capillary system may be greater or less 
than natural: hence arise two different morbid conditions, hy.- 
percemia, and ancemia. 



ARTICLE I. 



HYPEREMIA OF THE LUNG. 



There is no organ in the body which is more frequently 
found after death in a state of congestion than the lung. In 
fact, whenever an individual dies with any quantity of blood in 
his system, the lungs are invariably found gorged with that fluid, 
especially in their posterior part, to which the blood gravitates 
when the body lies, as it generally does on its back. Even in 
those cases where the individual dies in a state of general 
anaemia, the most dependent portions of the lungs are usually 
found in a state of sanguineous congestion. This congestion 



PARENCHYMA OF THE LUNGS. 317 

is most considerable in those cases where the mortal struggle 
has been long protracted, and in those where death from 
asphyxia occurs in consequence of a mechanical obstacle to 
the pulmonary circulation produced by some organic affection 
of the heart. 

It is, then, in the lungs as in the intestines, where, as we have 
already seen, a local accumulation of blood may be found in 
the dead body, which has had no share in producing any of the 
morbid phenomena observed during life, but was formed during 
the last moments of existence, or after life had ceased alto- 
gether. Hence it follows, that the existence of a simple con- 
gestion, especially when it occupies the most dependent por- 
tions of the lung, is not sufficient to prove that a process of 
irritation or inflammation had been going forward there during 
life. Does an alteration in the consistence of the part afford a 
more certain criterion to judge by in such cases? For a long 
time I was of opinion that when the lung was red and gorged 
with blood at its posterior portion, and at the same time was 
softer and more easily broken down than natural, it was a proof 
that the hyperamia was caused by inflamation ; but I have 
since altered my opinion, and am now convinced that when- 
ever the sanguineous congestion is so great that the lung con- 
tains a larger proportion of blood than of air, the pulmonary 
parenchyma is invariably soft and friable. The reason of this 
fact will readily be understood, if we reflect that, when the 
lung contains a much larger proportion of air than of blood, 
the parietes of the bronchia, when pressed by the finger, press 
in their turn on the compressible fluid they contain, and in this 
way, by compressing or expelling the air, retire before the 
pressure of the finger, and so escape being ruptured. But, 
when the lung contains a larger proportion of blood than of air, 
the former fluid being almost wholly incompressible, the pul- 
monary tissue cannot recede from under the finger, and is 
therefore easily ruptured. 

In the cases hitherto considered, the hyperemia of the lung 
was a mere passive phenomenon, principally formed after 
death ; but in another classs of cases, the symptoms observed 
during life afford unequivocal proof that the pulmonary con- 



318 DISEASES OF THE 

gestion found after death was formed during life, and produced 
by inflammation. Now, as the anatomical characters of the 
hypersemia are precisely the same in both these cases, it fol- 
lows that, in this instance at least, the true nature of the mor- 
bid lesions found on dissection can only be known by the na- 
ture of the symptoms observed during life. 

Active hypersemia (inflammation) of the lung presents two 
degrees. In the first, which alone can be confounded with 
the passive congestion, the bronchia are still permeable to air ; 
the parenchyma of the lung is of a brownish red or vermillion 
colour, and, when cut into, exudes a frothy sanguinolent fluid 
mixed with air. If a lung in this state be pressed between the 
fingers, it is easily ruptured, and its friability is greater in pro- 
portion as the fluid which flows from it is less frothy : it also 
becomes less crepitous in the same proportion. It may not be 
improper to remark, that those lungs which have naturally a 
greater degree of density, crepitate but very little. I mention 
this, because the habit of examining only the lungs of men 
might lead to the mistake of viewing as a morbid condition 
the deficient crepitation which is a natural phenomenon in the 
lungs of children and of several animals. 

In proportion as the quantity of air diminishes, and its place 
is occupied by blood, the parietes of the small bronchia and of 
the air cells, as well as the cellular tissue interposed between 
them, become more and more swoln, until at length a period 
arrives when these cavities are no longer permeable to the air, 
or are only so in a very few points. This constitutes the 
second degree of hypersemia, which authors have described 
by the name of hepatization. The resemblance which the 
lung in such a state bears to the parenchyma of the liver is 
very striking. When it is cut into, a small quantity of blood 
exudes from the divided surface, but not a particle of air ; if we 
press it under the finger, its tissue appears to have become re- 
markably friable, and is broken down with the greatest facility ; 
and if it be cut into slices, and thrown into water, it sinks to 
the bottom. Sometimes the hepatized lung presents a granu- 
lated surface when divided with the knife, or torn asunder ; 
in other cases the granular appearance is altogether wanting, 



PARENCHYMA OF THE LUNGS. 319 

and its surface, when cut, appears perfectly smooth. The 
granular appearance seems to me to depend on the degree of 
tumefaction which the air cells undergo ; for when the tume- 
faction passes a certain limit, its effect is to approximate the 
cells so closely that they become confounded together, and the 
granulated appearance vanishes entirely. 

If a piece of lung presenting either of the degrees of hy- 
peraimia, congestion, or hepatization, just described, be care- 
fully dried, it becomes quite evident that these alterations are 
formed in the manner we have described. When the lung is 
in the first degree of hypersemia, the only morbid appearance 
it presents when dried is a reddish, yellow, or brown tinge in 
the parietes of its capillary bronchia and air cells ; and in some 
cases even this shade of colour is wanting, and the lung which, 
before being dried, presented a remarkable degree of conges- 
tion, when dried differs in no respect from a healthy lung. 
When the experiment of drying is tried on a hepatized lung, 
the parietes of the capillary bronchia and of the air cells inva- 
riably present a red colour, and are moreover considerably 
thickened, so as to cause in some points a remarkable diminu- 
tion, and in others a total obliteration of their cavities. Whether 
the blood is simply accumulated in the vessels, or is effused into 
the coats of the air cells and bronchia, it is difficult, perhaps 
impossible, to determine ; but this much at least is certain, 
that the morbid alteration known by the name of hepatization 
of the lung, is altogether produced by a considerable degree 
of sanguineous congestion of the parietes of the capillary 
bronchia and air cells, the effect of which is to diminish or ob- 
literate their cavities. Even in those parts where the hepatiza- 
tion seems most perfect, it rarely happens that some small 
bronchial tubes may not be found still permeable to air ; and 
we sometimes find that when the lobe of a lung which appear- 
ed uniformly hepatized throughout, is dried and carefully ex- 
amined, we can discover some capillary tubes and air cells 
which, instead of having their caliber diminished, are very con- 
siderably dilated, and are at the same time free from any ap- 
pearance of congestion. 



320 DISEASES OF THE 

The two degrees of hyperemia, the nature and form of 
which we have been engaged in considering, present three 
principal varietes in the extent which they occupy. In the 
first, the hyperemia extends over an entire lobe, the whole of 
which appears in a state of congestion or hepatization (hypere- 
mia lobaris). In the second variety, some lobules separated 
from each other by other sound lobules are the seat of the hy- 
peremia Qiypercemia lobularis). In the third and last variety, 
it is not even an entire lobule, but some fractional parts of it, 
or in other words, some of the air cells which compose it that 
alone are affected with hyperemia (hyperemia vesicularis). 
This last variety may exist only in a few points, or may show 
itself in the form of an infinite number of red granulations dis- 
persed through the entire parenchyma of the lung : the same 
remark is also applicable to the second variety. 

In the lung, as in other parts of the body, gangrene may suc- 
ceed to every species of hyperemia, whether mechanical or 
vital, provided it be so considerable as to impede or prevent the 
afflux of arterial blood to the part. I have already shown that 
gangrene is not necessarily preceded by any violent degree of 
irritation ; but on the contrary, may be produced by any cause 
which retains the blood in the capillaries of the part, especially 
if by such stagnation the arrival of fresh blood by the arteries is 
prevented. In some persons, the slightest stagnation of the 
blood has a remarkable tendency to be followed by gangrene 
of the part : this disposition to gangrene, which in these per- 
sons is constitutional, may be produced in others by the intro- 
duction of certain substances into the circulation, such as the er- 
got of rye, the poison of certain reptiles, &c. 

Gangrene of the lung sometimes succeeds to a violent irrita- 
tion and hepatization of that organ ; while, in other cases, it 
makes its appearance unpreceded by any symptom of irritation 
whatever, and in others, again, the irritation which precedes it 
is slight, and of a chronic character, and such as occurs in a 
thousand cases without ever producing any such consequence. 
Thus the parenchyma of the lung sometimes becomes gangre- 
nous around tuberculous cavities, or around one or more bron- 



PARENCHYMA. OF THE LUNGS. 321 

chia that had been for a long time the seat of some chronic ir- 
ritation. 

Gangrene of the lung, from whatever cause it originates, pre- 
sents the following forms. 

1. Uncircumscribed. The interior of the lung then presents 
one or more undefined patches in which its parenchyma is re- 
markable for its gangrenous fetor, brown or livid color, and di- 
minished consistence. 

2. Circumscribed. In this form of the disease, the pulmo- 
nary parenchyma is, for a defined space, transformed into an 
eschar, which, as in all other parts, has a constant tendency to 
limit its extent, and to be eliminated. In order to accomplish 
this object, a process of suppuration is established around it, one 
or more bronchia are perforated, and the eschar, reduced to a 
fluid mass, is thrown off with the matter of expectoration. 
There then remains in the lung, in the place occupied by the 
eschar, an ulcerous cavity, filled with a dirty greyish fluid, which 
exhales an abominably fetid odour. The parietes of this cavity 
are in general not lined by any false membrane; the pulmonary 
parenchyma which surrounds it is in some cases perfectly 
healthy, and in others, more or less diseased. 

There is yet another species of hyperaemia of the lung, in 
which the blood, instead of accumulating in the parietes of the 
bronchia and air cells, escapes from its vessels, ruptures those 
parietes, and is collected into a clot in a cavity formed for itself 
in the parenchymatous substance of the lung. This constitutes 
the true pulmonary apoplexy, very different from that we have 
already described, where the only morbid change was the accu- 
mulation and coagulation of a certain quantity of blood in the 
bronchia. Here, on the contrary, the substance of the lung is 
ruptured and torn by the extravasated blood, just as the sub- 
stance of the brain is in cerebral apoplexy. The haemorrhage 
may be so extensive, that the greater portion of the lung is re- 
duced to a soft fluctuating mass, in which there can only be dis- 
tinguished some debris of pulmonary parenchyma, and a quan- 
tity of effused blood, partly coagulated and partly fluid. Such 
a haemorrhage may take place very rapidly, and produce death 
in a few hours, or even in a shorter time. In other cases, the 
Vol. II. 42 



322 DISEASES OP THE 

haemorrhage is less extensive, takes place more slowly, and is 
productive of less alarming consequences. Sometimes the 
haemoptysis to Which it gives rise, continues for some days ere 
it proves fatal. Another variety of this affection is that where 
the blood passes from the interior of the lung into the sac of the 
pleura, having ruptured that membrane as well as the interven- 
ing parenchyma. Lastly, there are some cases in which, as in 
cerebral haemorrhage, a series of phenomena are observed, the 
object of which is to promote the absorption of the effused 
blood, and in this way to effect a cure. Such appears to have 
been the case in those instances where the clot of a pulmonary 
apoplexy was found* surrounded by a well organized cyst, the 
internal surface of which was in all probability destined to be- 
come an agent of absorption. 

It sometimes happens that the blood extravasated in the lung, 
instead of being absorbed, has a tendency to acquire, as it were, 
a right of settlement there, by becoming organized, and thus 
rendered capable of performing the different acts of nutrition 
and secretion. 



ARTICLE II. 



ANAEMIA OF THE LUNG. 



In some bodies, the parenchyma of the lungs is found com- 
pletely exsangueous. Such a state of the lung is no more to 
be regarded as healthy, than that in which it is found more or 
less gorged with blood. It may depend on three different cir- 
cumstances. 



+ Bouillaud. Archives de Mkkcine, Novembre, 1826. 



PARENCHYMA OP THE LUNGS. 323 

1. On the sort of death which the individual dies : thus, the 
lungs of animals bled to death are found in this state. 

2. On the diminution of the process of hsematosis ; as occurs 
in several chronic affections, where the blood is found deficient 
in the lungs as well as in the other organs. 

3. On a state of atrophy of the pulmonary parenchyma. This 
condition of the lung may occur at any age, but is found most 
frequently in old persons. In these cases, one is tempted at 
first sight to regard those colourless lungs as models of health; 
but, on more attentive examination, we discover that there is a 
morbid diminution of their density, the place of a certain num- 
ber of air cells being occupied merely by cellular tissue. 



CHAPTER II. 



LESIONS OF NUTRITION. 



These are hypertrophy, atrophy, and transformation. The 
transformations of the pulmonary parenchyma are not very nu- 
merous : the parietes of the air cells are sometimes converted 
into bone ; (an example of which is related, page 308,) and the 
cellular tissue is occasionally replaced by fibrous or cartilagin- 
ous tissue. The observations that follow apply principally to 
the hypertrophy and atrophy of the pulmonary tissue, on which, 
as I shall endeavour to show, several alterations in the form of 
the lungs depend. 



324 



DISEASES OF THE 



ARTICLE I. 



HYPERTROPHY OF THE LUNG. 



The lung presents two species of hypertrophy. In one, 
there is simply an increase in the density of its parenchyma, 
without any alteration of its consistence. In the other, its con- 
sistence is likewise increased, or, in other words, the hypertro- 
phy is combined with induration of the pulmonary tissue. The 
first species of hypertrophy appears to me to be the result of an 
increase in the number of the septa which serve to divide the 
minute ramifications of the bronchia into the still minuter air 
cells, at the same time that there is likewise an increase in the 
capacity of these cells. This opinion is supported not only by 
the appearance which the lung presents, but likewise by the 
circumstances under which this hypertrophy takes place. Thus, 
Laehnec, has remarked that in several cases where one of the 
lungs is incapable of performing its functions, as in effusions of 
air or fluid into one of the pleurae, and especially when one 
side is contracted, as sometimes happens after the absorption of 
a pleuritic effusion, the lung of the sound side acquires a volume 
evidently greater than natural. In all such cases, the tissue of 
the lung is remarkably dense and compact, the lung itself does 
not collapse when the chest is opened, and it presents a striking 
resemblance to the lungs of children or of horses, which, as I 
have already stated, possess a much greater degree of density 
than naturally belongs to the lung of an adult man. This spe- 
cies of hypertrophy may take place in a short time. Laennec 
saw it particularly well marked in a man who, six months be- 
fore his death, had had a pleuritic effusion followed by contrac- 
tion of the affected side. Its production results from the fulfil- 
ment of a law in the animal economy, by virtue of which every 



PARENCHYMA OF THE LUNGS. 325 

double organ becomes the seat of a more active process of nu- 
trition when its fellow ceases to act. In this case it is the in- 
creased activity of function which induces the increased activity 
in the nutritive process. 

Hypertrophy of the pulmonary tissue unaccompanied by any 
induration properly so called, presents one variety which merits 
our attention : I allude to that form of it, where, at the same 
time that the parietes of the capillary bronchia and air cells are 
thicker than natural, their capacity is also considerably increas- 
ed. This is rendered very evident by inflating and drying the 
lung; for when, after this process, it is cut into slices, we at 
once perceive some cells much larger than in the natural state, 
and likewise some septa much thicker than they usually are. 
This form of hypertrophy, which constitutes one of the varieties 
of pulmonary emphysema, is of very frequent occurrence in 
persons labouring under chronic catarrh. In such persons, the 
dilatation of a certain number of air cells with hypertrophy of 
their parietes not unfrequently co-exists with a diminution of 
capacity or even obliteration of other air cells, the walls of 
which have increased in thickness at the expense of the cavity 
which they surround. In like manner, hypertrophy of the pari- 
etes of the heart sometimes co-exists with the dilatation, and 
sometimes with the contraction of its cavities. 

But it is principally in those cases of hypertrophy of the lung 
in which there is likewise induration of its tissue that the air 
cells are obliterated. When a lung in this state is dried and 
examined, we perceive a considerable extent of surface in 
which not a trace of any cavity can be distinguished ; it appears 
one solid tissue, evidently formed of the ordinary septa increas- 
ed in thickness and consistence. Here and there only, a few 
small cells are to be seen, the rudiments of the cavities which 
should naturally exist. 

The induration of the lung may be accompanied by different 
alterations of its colour. It very seldom presents a red shade, 
being much more commonly either yellow, grey, brown, or 
black. The black induration of the pulmonary parenchyma 
differs, in my opinion, in no respect from the grey or yellow 
induration of the same part, except in colour; and, as we can 



326 



diseases or the 



trace all the intermediate shades by which these different col- 
ours pass one into the other, I can see no reason for supposing 
the developement of a new tissue (melanosis), wherever the 
lung is indurated and presents a black colour. Why not as 
well make an accidental tissue of another portion of lung which 
is as much indurated and impenetrable to air as the preceding, 
and differs from it only in being yellow or grey instead of black? 

Induration of the pulmonary tissue, though identical in its 
nature, presents such a difference in its form and appearance, 
according as it occupies a lobe, a lobule, or only a part of a 
lobule, that it has been mistaken for different lesions, when in 
fact the only variety it offered was in the seat it occupied. 
Thus, Bayle considered the grey induration of some isolated 
air cells as an accidental tissue, to which he gave the name of 
granulation. The term, as a descriptive one, is certainly cor- 
rect enough, for these indurated cells resemble exactly. so many 
little grains scattered through the substance of the lung ; but as 
regards the nature of the alteration, an attentive dissection will 
readily convince us that the pulmonary granulations of Bayle 
are neither an accidental tissue sui generis, as he thought, nor 
the first stage of tubercle, as Laennec and Louis supposed, but 
simply certain vesicles or air cells in a state of induration. 
Previous to becoming hard and grey, these cells were soft and 
red ; surely, in this earlier stage of their formation, no person 
would consider them otherwise than as a cluster of cells 
in a state of hyperaemia. Few anatomists, I believe, would 
venture to assert that an entire lobe is changed into an acci- 
dental tissue, because it was at first soft and red, as in pneumo- 
nia, and subsequently became hard and grey. But that which 
happens in an entire lobe may likewise occur in a few cells; 
the nature of the lesion is the same, the only difference is, that 
it is less extensive. 

Any one may convince himself of the nature of these pul- 
monary granulations, by examining them either in a fresh lung, 
or in one which has been previously dried. In the latter, the 
following appearances are presented, provided the lung be 
healthy in the interval between the granulations. A number 
of small round or elongated bodies, of an opaque grey colour, 



PARENCHYMA OF THE LUNGS. 327 

present themselves to view. The pulmonary tissue around 
them is sometimes perfectly healthy; at other times the parietes 
of the neighbouring bronchia and air cells are thickened, and 
present the same greyish colour as the granulations. Several 
of the cells whose parietes are thus thickened are very much 
dilated ; but in general wherever the thickening of the parietes 
is considerable, the cells lose their regular form, and their ca- 
pacity diminishes. Let us suppose this thickening of the walls 
to proceed one degree further, we shall then have their cavities 
completely obliterated, and themselves converted into those 
homogeneous grey bodies which constitute the granulations. 

To recapitulate, pulmonary granulations are formed by a 
succession of the following alterations : 

1. The parietes of the air cells are injected. 

2. They become tumid and swoln, but still retain their red 
colour. 

3. They lose their red tinge, and acquire in its stead a grey 
colour, and at the same time increase progressively in thickness. 

4. Whilst the walls of the cells thus increase in thickness, 
their cavities undergo various alterations : sometimes their ca- 
pacity is increased, sometimes diminished, and in some in- 
stances altogether obliterated, and the granulation is then 
formed. It is almost needless to remark that, during any of 
the above stages, the part is liable to ulceration, or may secrete 
either pus or tubercle. All these appearances may readily be 
observed by drying a lung containing these granulations, cutting 
it into layers, and examining them in the sun. 

The cellular tissue which isolates the lobules of the lung from 
each other is sometimes indurated ; this alteration may either 
be confined to the cellular tissue, or may extend to the lobules 
which it invests. When in a state of induration, it becomes 
much more apparent than it usually is, and at the same time 
acquires a degree of density and hardness equal to that of 
fibrous tissue. In this state it is seen forming septa or partitions 
in the parenchyma of the lung, which resemble so many apon- 
eurotic expansions; and it sometimes even forms masses of 
considerable size and thickness, which compress the adjacent 
lobules, and prevent their dilatation, so that the proper tissue 



328 



DISEASES OF THE 



of the lung has a tendency to waste away in proportion as the 
interlobular cellular tissue is prelernaturally developed. Such 
is the series of phenomena which occurs in some cases; but, in 
others, the hypertrophy of the cellular tissue co-exists with a 
simple state of induration in the lobules it invests. 

Induration of the pulmonary parenchyma may continue for 
a very long time unaccompanied by any other alteration. It 
may, however, be followed by different morbid changes which 
have often been mistaken for the primary and principal affec- 
tion, when in point of fact they were only secondary. In this 
way, we sometimes observe a few tubercles in the midst of a 
lobe, the entire tissue of which is in a state of induration ; but 
their number is so inconsiderable that it is impossible to think 
they could have been the cause of the extensive induration 
which surrounds them. In such cases, the lesion of nutrition 
first takes place, and the lesion of secretion is but a secondary 
affection. I am anxious to insist on this fact, because I think 
the formation of tubercles in the lungs has been too generally 
regarded as the principal phenomenon in the morbid alterations 
of these organs ; as if all the other changes of texture were of 
subsequent formation and secondary importance. In the same 
way, I consider the black colouring matter which so often im- 
parts its hue to an indurated lung as merely a secondary phe- 
nomenon. The fact is, that this black matter is not, any more 
than tubercles, the source from whence in many instances 
originate the morbid appearances found in the dead body, or 
the symptoms observed during life. 

The older anatomists described under the name of ulcers of 
the lung those cavities which in modern times have been re- 
garded as the product of softened tubercles. This latter opin- 
ion is doubtless correct in many cases, but is certainly not so in 
all. It has repeatedly occurred to me to find a portion of pul- 
monary parenchyma in a state of induration, and containing 
one or more ulcerous cavities, when not a single tubercle was 
to be found in the entire lung, or, if a few were detected, they 
were very inconsiderable in size and number, and no more 
proved that the cavity had succeeded to the liquefaction of a 
mass of tuberculous matter, than the tubercles which are so 



PARENCHYMA OF THE LUNG. 329 

often found round the edges or at the bottom of intestinal ul- 
cers prove that those ulcers were caused by the softening of a 
submucous tubercle. Neither is there any reason for supposing 
that these pulmonary ulcers were preceded by the formation 
of an eschar ; they may, therefore, be regarded as primitive. 
Sometimes there is only one ulcer, and sometimes there are 
several, scattered through the substance of the lung. The in- 
duration of the surrounding tissues often precedes their forma- 
tion, but it may likewise follow a consecutive affection. 



ARTICLE II. 



ATllOPHY OF THE LUNG. 



Whenever any cause continues for a certain length of time 
to impede the free passage of the air into the pulmonary cells, 
those cells diminish in number, and the parenchyma of the 
lung falls into a state of atrophy. Accordingly, we find this 
atrophy invariably taking place in those persons who have had 
a pleuritic affection of long standing : the same effect is often 
produced by the presence of tubercles, and likewise by the hy- 
pertrophy of the cellular tissue described in the foregoing 
article. In a preceding part of this work I related a remark- 
able instance of atrophy of the lung, in a case where the prin- 
cipal bronchial tube distributed to it was almost completely 
obliterated. 

I am inclined to think that the lungs in old persons some- 
times undergo so considerable a degree of atrophy that their 
chest is visibly contracted in consequence. At least, it is cer- 
tain that in several decrepid old men the thorax is found much 
less developed in its different diameters than at any other pe- 
riod of life ; and in such persons the lungs are small, contain 
Vol. II. « 



330 DISEASES OF THE 

very little blood, are remarkably light, and their whole tissue 
appears rarefied. 

In these cases, it is only by the diminution in the size of the 
lung, and by the apparent rarefaction of its tissue, that we can 
judge of the atrophy which it has undergone. But this altera- 
tion is capable of demonstration by the following procedure. 
Let a lung thus rarefied be inflated and dried, we then perceive 
a remarkable alteration in the disposition of the ultimate bron- 
chial ramifications, and of the air cells in which they terminate ; 
they no longer form distinct cavities separated from each 
other by complete septa. At first, these septa are only re- 
duced to a state of extreme tenuity ; but at a later period, 
some of them appear perforated in one or more points, while 
others seem ruptured and irregularly torn. In some cases, the 
walls of the cells disappear altogether, and we only find in 
their stead some delicate lamina? or filaments traversing in dif- 
ferent directions cavities of various sizes. In the parts of the 
lung where these alterations exist, there are no longer to be 
found either bronchial ramifications, or vesicles, properly so 
called, but merely cells of greater or less diameter, divided into 
several compartments by imperfect septa, or irregular lamina?. 
Many of these cells bear a perfect resemblance to the lung of 
the tortoise tribe, and they all approach to it more or less, as 
to a type of organization, towards which the human being in 
this case seems to descend. 

Thus we see how lesions very different in their nature, hy- 
pertrophy on the one hand, and atrophy on the other, may both 
produce in the lung the same effect, namely, the transformation 
of the minute air cells into large vesicular cavities. But, in the 
case of hypertrophy, there is only dilatation of the cells with- 
out laceration of their parietes, unless as an accidental occur- 
rence; whereas, in atrophy of the lung, these large cavities are 
formed by several cells being thrown into one by the thinning 
and rupture of their walls. Hence arises this important differ- 
ence, that, in the first case, the number of the surfaces on which 
the blood is exposed to the action of the air remains the same ; 
while in the second, the number of those surfaces is considera- 
bly diminished. It is easy to see that the respiration will not 



PARENCHYMA OF THE LUNGS. 331 

be equally affected in these two cases ; and that the dyspnoea 
must necessarily be more considerable in the latter. There is, 
however, one circumstance which occurs in old persons (in 
whom, as I have already stated, atrophy of the lungs most gen- 
erally occurs) which prevents the respiration from being so 
greatly embarrassed as we might, a priori, expect from the 
diminution that takes place in the number of the surfaces for 
aerating the blood; and that is, the diminution in the quantity 
of their blood, or, what comes to the same thing, the diminution 
in the rapidity of their circulation. For this reason, atrophy 
of the pulmonary parenchyma, when occurring in old age, 
should rather be regarded as a natural phenomenon resulting 
from the fulfilment of a law in the animal economy which es- 
tablishes a constant proportion between the quantity of blood 
to be aerated in a given time, and the extent of the surface on 
which this aeration is accomplished. For the same reason it 
is that the lung has its maximum of density in infants, and in 
those animals which have either a very rapid circulation, or a 
very large supply of blood ; and that, on the contrary, the den- 
sity of the lung is at its minimum in old persons, and in such 
animals as receive into their lungs at each round of the circu- 
lation only a small proportion of the blood contained in their 
circulating system. 

However, we do occasionally meet with persons advanced 
in life whose respiration is greatly disordered, for which no 
other cause can be discovered than an unusual degree of this 
atrophy of the pulmonary tissue. 

Lastly, this alteration, which may in general be regarded as 
a natural occurrence in old age, sometimes takes place at an 
earlier period of life, and is then invariably productive of more 
or less dyspnoea. 

This transformation of the air cells into larger cavities, either 
by the simple dilatation of each cell, or by the destruction of 
their partitions, constitutes the lesion described by authors un- 
der the name of Pulmonary Emphysema. 

The theory I have now given of the formation of pulmonary 
emphysema would be incomplete, if I were not to add, that it 
is sometimes produced in a manner purely mechanical. In this 



332 DISEASES OP THE J 

way it is often formed in horses, in whom emphysema of the 
lungs is a disease of constant occurrence, and, as I believe, of- 
ten produced by the violent efforts which those animals are 
compelled to make. I have repeatedly examined horses' lungs 
in a state of emphysema, and always found the affection to 
consist, 1. in a simple dilatation of the minute bronchia and air 
cells; 2. in a rupture of their parietes; and, 3. in an infiltration 
of air into the interlobular cellular tissue. The first of these 
alterations appears to precede the second, and the latter, I be- 
lieve, never occurs but as a consequence of the others. It is 
very probable that it is likewise in a manner quite mechanical 
that emphysema of the lungs is formed in persons labouring un- 
der old catarrhal affections, attended with violent paroxysms 
of coughing. It would be interesting to ascertain whether those 
persons whose occupation constantly obliges them to make great 
efforts, are not more subject than others to emphysema of the 
lungs.* 

When the emphysema is not considerable, it requires a prac- 
tised eye to recognize it in the fresh lung; but the difficulty 
ceases when the lung is inflated and dried. I am confident 
that in many cases the lungs of asthmatic patients have been 
regarded as healthy, when they were in reality emphysematous, 
and that in this way several cases of dyspnce were set down as 
essential, for which anatomy has now discovered an organic 
cause. 

When the emphysema is more considerable, it may be at 
once detected by simple inspection. Sometimes it appears in 
the form of bullae, which project more or less above the exter- 
nal surface of the lung; at other times, there is no projection 
on the surface, but underneath the pleura are perceived one or 
more points where the air cells are converted into large vesi- 
cles. In some cases, these vesicular cavities are not perceptible 



♦I have been assured by a physician to the hospital at Fontainbleau, where a 
great number of quarry men die who are constantly in the habit of raising large 
blocks of stone, that their lungs are frequently found emphysematous. The fact 
is curious, and deserves to be investigated. 



PARENCHYMA OF THE LUNGS. 333 

externally, but exist in the interior of the pulmonary paren- 
chyma, where I have often seen them, especially in the horse, 
forming cavities of considerable size. 



CHAPTER III. 



LESIONS OF SECRETION. 



The same morbid secretions are found in the lung as in all 
the other organs, but they are not all equally common. Thus, 
a purulent abscess in the lung is a very rare occurrence, while 
there is no part of the body in which tubercle and melanosis are 
so frequently deposited. Whatever be the nature of the mor- 
bid secretion, it must be deposited in one of three points ; either, 
1. in the cavity of the air cells ; 2. in their parietes ; or, 3. in 
the cellular tissue interposed between them. Many of them 
have been already fully described ; melanosis, for instance ; in 
treating of which in the first volume, I took occasion to de- 
scribe whatever particularities it presents when seated in the 
lung : to that description I must therefore refer the reader. 

Calculous concretions, composed in the lung, as elsewhere, 
of calcareous phosphate, possess very little interest as an isola- 
ted aflfection : they seldom, however, exist in the lung without 
some other alteration accompanying them ; indeed, they almost 
always co-exist with tubercles, of which they appear to be one 
of the terminations. Their usual situation is in the summit of 
the lung, where they are sometimes found mixed up with tu- 
berculous matter, in the form of irregular masses, or of fine 
grains like sand ; in other cases, they are found without any 
admixture of tuberculous matter, and generally surrounded by 
the pulmonary parenchyma in a state of induration and of a 
deep black colour : lastly, they are occasionally found in cavi- 



334 DISEASES OF THE 

ties that are probably the remains of old tuberculous excava- 
tions. 

The only entozoa which have as yet been observed in the 
human lungs, are the acephalocysts : they are always found en- 
closed in cysts, round which the parenchymatous tissue of the 
lung may either be simply compressed, indurated, or reduced 
to a state of atrophy. In one case, an entire lobe of the lung 
was transformed into a large cyst of hydatids ; and in another, 
which I have elsewhere described, the acephalocysts were 
lodged in the interior of the pulmonary veins, which were great- 
ly dilated.* 

There are two other alterations of secretion, which, as I have 
already described I shall now only briefly allude to. One of 
these consists of a preternatural exhalation of serous fluid into 
the cellular tissue of the lung. This disease, which Laennec 
described under the name of cedema of the lung, is sometimes 
idiopathic, but more generally coincides with a general leuco- 
phlegmatic state of the system. M. Billard states that he has 
observed it in new-born infants affected with that peculiar dis- 
ease, hardening of the cellular tissue. The other alteration 
consists of an effusion of gas into the cellular tissue that unites 
the lobules of the lung together. It is this effusion which Laen- 
nec described as interlobular emphysema. In some cases, it is 
produced by an exhalation of gas ; but, in most instances, the 
air found in the interlobular cellular tissue is not generated 
there, but merely extravasated from a ruptured air cell. 

There yet remains two morbid secretions to be described, 
namely, pus and tubercle ; these I shall now proceed to de- 
scribe. 



* Clinique Medicale, torn. iii. 



PARENCHYMA OP THE LUNGS. 335 



§ I. Secretion of Pus. 



Pus is found in two forms in the parenchyma of the lungs, 
either collected into abscesses or infiltrating the pulmonary 
tissue. 

Purulent infiltration, which is by far the more frequent oc- 
currence of the two, may either occupy an entire lobe, or be 
confined to some isolated lobules. It is in general accompanied 
by evident traces of the red hepatization already described, and 
appears in the great majority of cases to succeed to the most 
violent degree of inflammation. The infiltration of the lung 
with purulent matter sometimes takes place with great rapid- 
ity ; it has been found fully formed in four days after the first 
symptoms of pneumonia had made their appearance. 

The pulmonary parenchyma, when infiltrated with pus, pre- 
sents a greyish ash colour, and as the second stage of pneumo- 
nia has received the name of red hepatization, so this in contra- 
distinction has been termed the grey hepatization. When a 
lung in this state is pressed, the purulent fluid exudes in greater 
or less quantity ; and when it is all squeezed out, the lung fre- 
quently re-assumes the red colour and hepatized appearance of 
the second stage, thus proving unequivocally that the grey 
hepatization diners only from the red in having its structure in- 
filtrated with pus. The consistence of the lung is considera- 
bly diminished in these cases ; it breaks down readily when 
handled, and in some instances is so extremely soft, that the 
slightest touch is almost sufficient to reduce it to a greyish pap, 
in which not the least trace of organized structure can be de- 
tected. Indeed, you may even squeeze all the purulent matter 
towards one point, and thus form an abscess in the dead lung. 

When we examine with a lens a lung in the state of puru- 
lent infiltration, we obtain the following results. 

In some cases the surface under examination presents an in- 
numerable multitude of minute grey granulations, of sirnilar 
form and size, closely pressed together. These granulations 



336 



DISEASES OF THE 



cannot, I conceive, be considered in any other light than as the 
air cells altered in that peculiar manner we have already de- 
scribed in the red hepatization, the only difference being that, 
in this case, they are grey instead of red. In other instances 
we only observe a smooth surface without any granufar ap- 
pearance ; which probably arises from the granulations not 
being sufficiently developed, or else from their being so closely 
crowded together as to run one into the other, and thus form a 
uniform surface. Lastly, in those parts where the lung appears 
to the naked eye deprived of its consistence, and, as it were, 
macerated in pus, the magnifier shows us that the structure of 
the parenchyma is completely broken down, and converted 
into a reticulated cellular structure, the meshes of which are 
large and filled with pus. 

The arteries and veins leading to the infiltrated points usually 
continue free from disease ; in some cases, however, they are 
implicated, and are even sometimes the principal seat of the 
suppuration. Thus, in a case which I examined with M. Rey- 
naud, where some of the pulmonary lobules seemed to be in a 
state of purulent infiltration, on closer examination we found 
the principal branches of the pulmonary artery filled with 
blood mixed with pus, the smaller branches were filled widi 
pure pus, and were easily traced running into all the diseased 
lobules ; indeed the appearance of purulent infiltration which 
they presented seemed principally to depend on this state of 
the minute branches of the pulmonary artery. 

There are in like manner certain cases of red hepatization, 
which on close examination we can distinguish from the more 
ordinary form of this alteration ; for, when cut into, the orifices 
of the divided bronchia, instead of being obliterated, as in the 
ordinary form, remain open, and seem even more dilated than 
usual, but the blood-vessels are plugged up with coagulated 
blood. Let us suppose this blood deprived of its colouring 
matter, and its ordinary degree of consistence diminished, and 
we shall then have the morbid alteration described in the 
preceding paragraph; is it not reasonable, then, to conclude, 
that these two states are merely different degrees of the same 
morbid alteration ? And if we suppose the fibrine, instead of 



PARENCHYMA OF THE LUNGS. 337 

being perfectly liquefied, as in the preceding case, to lose only 
a part of its consistence, shall we not then have, instead of 
purulent infiltration, an apparent infiltration of tuberculous or 
encephaloid matter ? 

A collection of pus formed in the parenchyma of the lung, 
so as to constitute a genuine abscess, is an extremely rare mor- 
bid appearance. It is strange how Laennec, who was perfect- 
ly aware how rare a phenomenon it is in the dead body, could 
have been led into the error of describing it as a common oc- 
currence in the living subject. He states that in one year he 
ascertained the existence of twenty abscesses of the lung: 
surely this must have been a mistake. 

M. Sestier, resident pupil at the Hbpital des Enfans- 
Trouves, showed me the lung of a new-born infant, whiph con- 
tained several large abscesses : they had no resemblance what- 
ever to tuberculous excavations. I believe that no such ap- 
pearance has ever been observed at any other age. 

It is not only as the sequel a3 of inflammation that abscesses 
are formed in the lung ; they likewise occur, and perhaps even 
more frequently, in cases where the lung seems merely to re- 
ceive into its tissue a certain quantity of pus which had been 
formed in some other part, and was only conveyed thither by 
the torrent of the circulation. Collections of purulent matter 
have of late years been frequently found in the lungs after cap- 
ital operations, the pulmonary tissue all round appearing per- 
fectly healthy. Similar collections have likewise been found 
in persons who had one or more organs at a distance from the 
lungs in a state of suppuration. Sometimes, in these cases, in- 
stead of an abscess we find a certain number of pulmonary 
lobules in a state of purulent infiltration. 

From an attentive examination of these cases,' I am disposed 
to range them in two classes. In one, it appears that the pus 
is formed in the torrent of the circulation, or is introduced into 
it from some organ in a state of suppuration, and in its passage 
through the parenchyma of the lung is separated as through a 
filtre, and is either collected into an abscess, or infiltrates the 
pulmonary tissue. Is it not by a similar process that mercury 
injected into the crural vein of a dog traverses the whole cir- 
Vol. II. 44 



338 DISEASES OF THE 

culating system until it arrives at the lung, where it abandons 
the circulating fluid ? In the other class of cases, some cause 
with which we are unacquainted alters the blood, coagulates 
it in the pulmonary vessels, and transforms it into purulent 
matter in the smaller branches of these vessels. I have dwelt 
particularly on these facts, because they prove, in conjunction 
with several others, that the cause of the suppuration of an 
organ is not always to be found in the organ itself; and, con- 
sequently, that the simple fact of pus being found in an organ, 
is not of itself sufficient evidence to prove that inflammation 
must necessarily have been going forward there. 



§ II. Secretion of Tubercle. 



According to most modern authors, the developement of tu- 
bercles in the lungs constitutes the anatomical character of 
pulmonary consumption. Bayle gave this term a wider signi- 
fication, and applied the name of phthisis to the disease depend- 
ant on any alteration of the lung that is usually followed by 
ulceration. In conformity with this idea, he admitted six dif- 
ferent species of phthisis. 

1. Tuberculous phthisis. 

2. Granular phthisis. 

3. Phthisis from melanosis. 

4. Calculous phthisis. 

5. Cancerous phthisis. 

6. Ulcerous phthisis. 

This classification of Bayle's is objectionable in many re- 
spects. As the term phthisis, taken in this extensive signifi- 
cation, only served to represent a train of symptoms which 
might result alike from the most different alterations of the 
lung, Laennec thought it would be beneficial to the interests of 
science to restrict its application to one of those alterations ex- 
clusively ; and accordingly the term phthisis is only applied by 
him to that morbid state which is produced by the presence of 



PARENCHYMA OP THE LUNGS. 339 

tubercles in the lungs ; and in this acceptation of the term is 
now generally used. 

The general history of tubercles has already been given in 
the first volume ; I shall therefore at present only describe the 
peculiarities they present when seated in the lung. In this, as 
in every other organ, they first appear as small, white, friable 
masses, which sooner or later become soft, and then tend to be 
eliminated from the lung, leaving behind them an ulcerous cavi- 
ty, which generally spreads more and more, in some instances 
remains stationary, and in a very small proportion of cases fills 
up and cicatrizes. 

It is rare to find only one tubercle in a lung ; and it is also 
rare to find them in one lung, and not in the other. Both 
these cases have, however, been observed. It is in the upper 
lobes that tubercles have the greatest tendency to be developed, 
where, according to M. Broussais, inflammation of the bron- 
chia is also most common. In some cases, they are formed in 
the interior of the lung ; in others, they are quite superficial, 
and situated immediately under the pleura, which they some- 
times irritate and perforate. 

When once a tubercle is developed in the lung, it may either 
be converted into a calcareous concretion productive of little or 
no inconvenience to the system, or it may soften, and be trans- 
formed into a cavity. The dimensions of these cavities are 
very variable; some are scarcely large enough to contain a 
nut, and others are so vast as to occupy the place of an entire 
lobe. In some cases, there is only one cavity ; in others there 
are several, which may either remain isolated, or communicate 
by fistulous passages. Some are situated at a distance from 
the surface of the lung ; others again are so superficial, that 
they are only separated from the pleura by a thin transparent 
layer of the pulmonary parenchyma. The pleura which covers 
these superficial cavities is in almost every instance united to 
the corresponding surface of the pleura costalis by cellular ad- 
hesions, which prevent the parietes of the cavity collapsing, as 
they do in the dead body when these attachments are removed. 
It occasionally happens that the cavity advances still nearer to 
the surface, reaches the pleura, and perforates it. In some 



340 DISEASES OF THE 

cases this accident is not productive of any inconvenience, as 
the contents of the cavity are prevented from escaping into the 
sac of the pleura by the adhesions which surround the perfora- 
tion, and bind the lung to the ribs. But, in general, the most 
fatal consequences follow; for, the moment the wall of the 
cavity is ruptured, its contents are poured into the cavity of 
the pleura, pneumothorax immediately ensues, and subsequent- 
ly an effusion of fluid from the pleura. A very small cavity, 
provided it be situated near the surface of the lung, may give 
rise to this accident, which generally proves fatal in a very 
short time, though in some cases the patient has lingered as 
long as thirty days. 

The interior of the tuberculous cavities is generally traversed 
by bands attached at both extremeties to the sides of the cavity. 
These bands contain some pulmonary tissue in a state of indura- 
tion, and blood-vessels generally transformed into impermeable 
fibrous cords. In some rare cases, however, these vessels con- 
tinue permeable, and by their rupture occasionally give rise to 
attacks of haemoptysis. The substance of the lung around the 
cavities is sometimes healthy, sometimes filled with tubercles in 
different stages, and sometimes indurated and of a grey or black 
colour. The walls of these cavities are generally formed by 
the parenchyma of the lung, either naked, or else covered only 
with an unorganized membraniform layer, apparently com- 
posed of the most concrete part of the purulent matter contain- 
ed, in the cavity. It is only under certain circumstances to be 
presently described that these walls are ever lined by fibrous 
or cartilaginous membranes. Their internal surface presents 
one or more openings by which the interior of the cavity com- 
municates with the bronchia, and which are in fact formed by 
the perforation of these tubes. A number of vessels creep 
along the sides of the cavity, but, unlike the bronchia, they al- 
most always remain whole and uninjured. 

The matter contained in tuberculous cavities is not always 
of the same description. Most commonly it is a whitish or 
greyish purulent fluid, in which are suspended a number of 
cheesy particles resembling the debris of tubercles. In other 
cases it is a homogeneous pus, variable in its colour and con- 



PARENCHYMA OF THE LUNGS. 341 

sistence. Blood, also, has been found in them, both fluid and 
coagulated; and I have myself seen fragments of the pulmonary 
parenchyma, totally detached and floating loose in the interior 
of the cavity. Lastly, calculous concretions are occasionally 
found in the cavities loose and unattached. Are these concre- 
tions formed there, or have they been detached from the sur- 
rounding parts of the pulmonary tissue? 

The cavities are not formed by the tissue of the lung being 
forced back and condensed; the parenchyma is really destroy- 
ed, and a true ulcer formed, which goes on constantly increas- 
ing in size, until its dimensions far exceed those of the original 
tuberculous mass. 

The older pathologists were of opinion that these ulcers 
were susceptible of being cicatrized. In our days, the possibil- 
ity of their cicatrization was at first positively denied, until the 
accurate researches of Laennec fully established that the opin- 
ion of the ancients was founded on fact, and that the cicatriza- 
tion of tuberculous cavitives does actually take place, though 
unfortunately in but a small proportion of cases. The follow- 
ing are the results of what has been observed on this subject. 

When a tuberculous cavity evinces a disposition to heal, the 
limits of the ulceration are marked by the appearance of a cel- 
lulo-fibrous membrane lining its walls; at the same time the 
purulent secretion ceases, and is replaced by the exhalation of 
a clear serous fluid. This, which may be considered as the 
first step in the sanative process, is soon succeeded by another, 
in which the cellulo-fibrous membrane changes its character; 
the fibrous layer grows thicker, and manifests a tendency to 
become cartilaginous; and the cellular layer assumes the ap- 
pearance of the mucous membrane lining the bronchia, and be- 
comes continuous with it. The sanative process does not, how- 
ever, stop there. Sometimes the sides of the excavation be- 
come agglutinated, and its cavity so completely obliterated 
that the only trace which remains of it is a cellulo-fibrous line, 
into which several large bronchial tubes run and terminate 
abruptly. Sometimes again the fibrous or cartilaginous layer 
developed round the excavation increases in thickness, and is 
transformed into an amorphous mass which fills up the cavity. 



342 DISEASES OP THE 

Lastly, it appears that, under certain circumstances, the exca- 
vation is filled up by an accumulation of phosphate of lime ; at 
least cases have been recorded of persons who, after present- 
ing the most unequivocal signs of a tuberculous excavation, and 
subsequently recovering, were found to have only a mass of 
calcareous phosphate in the situation where pectoriloquy and 
gargouillement had before been distinctly audible. 

These different traces of the obliteration of tuberculous cav- 
ities have been chiefly observed under the following circum- 
stances. 

1. In cases similar to the preceding, where, at some previous 
period of their lives, the individuals had suffered from a violent 
pulmonary attack which had been universally considered as 
phthisis. 

2." In cases where persons, after recovering from disease of 
the chest, were again seized with a similar attack, and died of it. 

3. In cases where, from the commencement of the pulmona- 
ry attack, the patients grew every day worse and worse. In 
these cases it would appear that as fast as one cavity was 
cicatrized, another was formed. 

Hence we see, that after the cicatrization of a cavity, the 
disease may still continue its progress by the formation of new 
tubercles and new cavities, or be suspended for a time, or lastly 
undergo a perfect cure and never return. 

The marks of cicatrization have as yet only been found in 
the situation where these cavities most frequently occur, name- 
ly, in the summit of the lungs, which in all such cases is de- 
pressed, shrunk, and puckered : the depression on the surface 
corresponding to the loss of substance in the interior of the 
lung is filled up by packets of false membrane, or else the par- 
ietes of the thorax give in, in order to accommodate them- 
selves to it. 

An interesting point in the history of tubercles is, whether 
they may be absorbed while still in a state of crudity, or 
whether they must first be softened and transformed into ab- 
scesses before they can be removed from the lungs. The 
question still remains to be decided ; however, the following 
observations may throw some light on the subject. 



PARENCHYMA OF THE LUNGS. 343 

I have sometimes been struck, when examining tuberculous 
lungs, with the singular form which some of the tubercles pre- 
sented ; at one side they retained the usual rounded form, but 
at the other they seemed to terminate in a sort of caudal pro- 
longation traversed by a deep groove. These tubercles were 
in the neighbourhood of several large bronchia. When ex- 
amining these tubercles it struck me that they might originally 
have been, like other tubercles, of a rounded form ; and that 
subsequently their central portion might have disappeared, 
either by absorption, or by passing molecule by molecule into 
the neighbouring bronchia ; the consequence of which would 
be the approximation of the parts not yet absorbed ; and in 
this way might be explained the transformation of the rounded 
into an elongated body, and the formation of a groove in its 
centre. These hints are only offered to induce others to pur- 
sue the investigation. 

The substance of the lung round the tubercles may be dif- 
ferently affected. 

1. It is sometimes perfectly healthy ; this is frequently the 
case where the tubercles are still in a state of crudity, but oc- 
curs more rarely when they are already softened, or converted 
into cavities. 

2. The pulmonary parenchyma may be emphysematous : 
this emphysema may either be produced by the dilatation of 
the air cells in the vicinity of the tubercles, thus establishing a 
supplementary respiration, or it may proceed from the atrophy 
and rupture of the walls of these cells. 

3. The parenchyma of the lung may be rendered imper- 
meable to the air by the induration and thickening of the pa- 
rietes of the air cells, or by its infiltration with serum, or with 
gelatinous fluid. Laennec was of opinion that the induration 
of the pulmonary parenchyma in the neighbourhood of tuber- 
cles was produced by the infiltration of the tissue of the lung 
with the tuberculous matter ; and he attributed to this infiltra- 
tion its impermeability to air, grey colour, and hardness: but 

these phenomena are much more satisfactorily explained by 
referring them to an extreme degree of induration and thick- 
ening of the pulmonary parenchyma. What analogy is to be 



344 DISEASES OP THE 

found between the matter of tubercle and the gelatiniform infil- 
tration which frequently exists round tubercles 1 none ; and 
yet Laennec described it as a species of tuberculous infiltra- 
tion, under the title of infiltration tuberculeuse gelatiniforme. 

The induration of the tissue of the lung in many cases does 
not commence until long after the formation of the tubercles, 
when they begin to soften and form abscesses : in some cases, 
however, it precedes the deposition of the tubercular matter, 
and, instead of being regarded as an effect, must in these cases 
be considered as at least an occasional cause of their develope- 
ment. What other conclusion can we come to in those cases 
where an entire lobe is found indurated and impermeable to 
air, with only a few miliary tubercles dispersed through its sub- 
stance ? Or, when (as still more frequently happens) several 
lobules are gorged with blood and infiltrated with serum, and 
a few tubercles are found in some of the diseased lobules, and 
none in others, is it possible to suppose that the diseased state 
of the lobules was produced by the presence of the tubercles ? 
or is it not more reasonable to suppose that the disease of the 
lobules preceded the formation of these tubercles. 

If we infiltrate and dry a lung containing tubercles, the pa- 
renchymatous tissue around them being apparently healthy, 
and after drying slice it into layers, we observe certain air 
cells whose cavity is dilated, and whose parietes are consider- 
ably thickened, and present a peculiar yellow tinge ; in some 
points this thickening becomes more considerable, and the yel- 
low tinge deeper; and in others we are enabled todistinguish 
in these thickened parietes a number of minute yellow round 
bodies, which are evidently tubercles. Here, then, we find 
certain lesions preceding the secretion of tubercles. But, in 
order fully to investigate this question of the etiology of tuber- 
cles, it would be necessary to examine the influence of every 
circumstance, whether internal or external, which is capable of 
promoting their developement. Such an inquiry, though ex- 
ceedingly interesting in itself, would be inconsistent with the* 
design of this work, in which I do not undertake to solve the 
question of the nature and causes of disease, but merely to 
show how far pathological anatomy can aid us in the solution 



PARENCHYMA OP THE LUNGS. 345 

of that question. From it we learn, that in those parts of the 
lung where tubercles are developed, we sometimes find no ap- 
preciable deviation from the healthy state ; that, in some cases, 
the lesions we observe can only be considered as effects pro- 
duced by the presence of tubercles ; and lastly, that, in certain 
cases, and those not the least numerous either, the morbid al- 
terations of the lung were evidently prior to the formation of 
the tubercles, and contributed to produce them. These altera- 
tions which precede the developement of tubercles are chiefly 
the following : 

1. Hypersemia of the bronchia of a certain size. 

2. Hyperaemia of the air cells and ultimate ramifications of 
the bronchia, without obliteration of their cavities. 

3. Hyperaemia of the same parts, with considerable thick- 
ening of their parietes, and obliteration of the cavities. 

4. An effusion of blood into the tissue of the lung ; the blood 
thus effused coagulates, becomes a living part, and secretes 
tubercle. 

Professor Cruveilhier has lately instituted a very interesting 
set of experiments on the different phenomena produced by in- 
jecting mercury into the blood-vessels; and has ascertained 
that by injecting this metal into the femoral artery of a dog, he 
caused the formation in the cellular tissue of a great number of 
small, white, round bodies, containing each a globule of mer- 
cury in its centre surrounded with a concrete cheesy pus. 
When the mercury was injected into the bronchia, the same 
results were obtained, white granular bodies, composed of con- 
crete purulent matter, with a globule of mercury in their cen- 
tre, were formed in the parenchyma of the lung, where they 
appeared to occupy chiefly the ultimate divisions of the bron- 
chia and the air cells. M. Cruveilhier thinks that he has in this 
way artificially produced the formation of tubercles. These 
experiments have since been repeated by Dr. Lombard, whose 
interesting researches on the subject of tubercles I have al- 
ready repeatedly alluded to. I have dissected with him the 
lungs of several animals into whose bronchia mercury had pre- 
viously been injected, and the following were the appearances 
we discovered. The mercury contained in the small bronchia 

Vox,. II. 45 



346 DISEASES OF THE 

was enveloped in a thick layer of puriform mucus, fluid in some 
points, and in others of the consistence of the false membrane 
of croup. In several places, the parietes of the bronchia were 
ruptured, and the mercury was effused into the substance of 
the lung and surrounded with purulent matter. These were 
the only appearances we observed, although the animals were 
examined at different dates after the experiment. I have no 
doubt, if these experiments were conducted on a larger scale, 
that genuine tubercles would be found in the lungs of some of 
the animals ; but I should be inclined to regard them in such 
cases as the product of a peculiar disposition brought into ac- 
tion by the irritation artificially created in the bronchia. 

Persons who die with tubercles in their lungs present on 
dissection various lesions, some of which are purely accidental, 
while others co-exist so frequently with the developement of 
tubercles in their lungs, that it is reasonable to suppose there 
exists some connexion between them. 

The most remarkable of these lesions is the formation of 
tubercles in a number of organs which have no connexion with 
the lung either in their structure or functions. ' This simulta- 
neous developement of tubercles in several organs occurs more 
particularly in children ; it is also very remarkable in animals 
from warm climates that die in our country. — (See the chapter 
on tubercles in the first volume.) 

The several lesions which co-exist with the developement of 
tubercles in the lungs, are to be found either in the organs of 
respiration or in other parts. 

The lesions of the organs of respiration reside : — 

1. In the larynx, which is rarely, if ever, found in a state of 
ulceration, unless where there are tubercles in the lungs. 

ii. In the trachea, in which the redness and ulceration are 
sometimes confined to the side corresponding to the lung in 
which the tubercles are most numerous and farthest advanced. 

3. In the bronchia, which, though generally red and in- 
flamed, are sometimes remarkably pale, and present a striking 
contrast to the extent of disease existing in the parenchyma of 
the lung. 



PARENCHYMA OF THE LUNGS. 347 

4. In the parenchymatous substance of the lung round the 
tubercles: these lesions have already been enumerated. 

5. In the pleura. In almost every case of tubercles, adhe- 
sions are formed between the pleura costalis and pulmonalis. 
These adhesions are the more firm, as the disease is more ad- 
vanced, and they are always strongest towards the summit of 
the lung. Some phthisical patients are taken off by an attack 
of pleuritis terminating in effusion, and others by pneumotho- 
rax caused by the opening of a tuberculous cavity into the 
pleura. 

The parts of the body not connected with the organs of res- 
piration usually present the following appearances in phthisical 
persons.* 



A. State of the Circulatory Apparatus in Phthisis. 



Increased size of the heart is a rare phenomenon in persons 
labouring under phthisis. In one hundred and twelve cases 
M. Louis only saw three instances of it. On the other hand, 
diminution of the heart's size is very common; it may exist 
with or without thinning of the parietes. The aorta is like- 
wise often diminished in size. 

A great deal has been said of the alterations of the lymphatic 
system in consumptive patients; but these remarks have in 
general been founded on theory rather than observation. The 
supposed alterations of the lymph itself are not supported by a 
single fact; and as to the lymphatic vessels, the only lesion 
which has been observed is that some of them occasionally con- 
tain tuberculous matter. The lymphatic ganglions are much 
less frequently diseased than is generally supposed ; for, in a 
large proportion of the adults who die of tuberculous affection 
of the lungs, there is no appearance whatever of disease in 



*Louis, Recherches sur la Phthisie piUmonaire; and my Clinique Medicate. 



348 DISEASES OP THE 

them ; in children, indeed, they are oftener diseased, and not 
unfrequently contain tubercles. 

There is nothing very particular in the appearance of the 
spleen in phthisical patients. 



B. State of the Digestive Apparatus in Phthisis. 



This apparatus is decidedly the one most frequently affected 
in consumptive persons. Softening of the mucous membrane 
of the stomach, hyperaemia of the different portions of the in- 
testines, ulceration of the small intestine, accompanied in many 
instances by a developement of tubercles, are all of such fre- 
quent occurrence in phthisis, that they may be fairly consid- 
ered as constituent parts of the disease. These lesions may 
either precede or follow the formation of tubercles in the lung; 
and in some cases the pulmonary and abdominal affections set 
in together. 

It has been stated that fistula in ano is a frequent complica- 
tion with tubercles in the lungs. The result of my observa- 
tions does not confirm this assertion. 



C. State of the Secretory Apparatus in Phthisis. 



The cellular tissue is deprived of its fat : it is very rarely 
infiltrated with serum. It is also rare to find effusions in any 
of the serous cavities. In almost every case, as already stated, 
the pleura becomes irritated, and covered with false membranes, 
which frequently secrete tubercular matter. Perforation of 
the intestine occasionally produces inflammation of the peri- 
toneum. 

The fatty degeneration of the liver was observed by M. Louis 
in a third of all the phthisical patients whom he examined ; and 
out of forty-nine cases of fatty liver which he met with in his 
dissections, forty-seven were cases of phthisis. Hence he con- 



PARENCHYMA OP THE LUNGS. 349 

eludes that this morbid alteration, so common in phthisical pa- 
tients, belongs almost exclusively to them. The liver is never 
found in this state until after the tubercles in the lungs have 
been softened, and transformed into cavities. 

This fatty degeneration is the only morbid change which the 
liver can be said to exhibit in phthisis. The only cause of 
jaundice I ever observed in this class of patients was in a case 
where I found the biliary ducts compressed by masses of tu- 
bercle. There is nothing peculiar in the colour of the bile ; 
biliary calculi are exceedingly rare in those cases. 

M. Louis found the urinary organs healthy in three-fourths 
of the phthisical patients whom he examined. In the other 
fourth there were a variety of lesions, but none of them seemed 
peculiar to phthisis. The result of my own observation is like- 
wise that the urinary organs are seldom diseased in consump- 
tive cases. 



D. State of the Nervous Apparatus in Phthisis. 



The only peculiarity which the nervous system presents, is, 
that in this, as in other chronic complaints, it is generally paler 
and softer, than natural. The functions of the brain are seldom 
deranged; sometimes, indeed, there sets in shortly before death 
a state of delirium, but I do not think it can be accounted for 
by any appreciable lesion of the cerebral organs. 



E. State of the Apparatus of locomotion in Phthisis. 



There are very few diseases in which the muscles become so 
completely atrophied as in pulmonary consumption. They 
seldom, however, contain tubercles.^ The opinion lately pro- 
mulgated by M. Larcher, that, in phthisis, the bones contain a 
less proportion of phosphate of lime, seems to me merely con- 
jectural ; at least it needs confirmation. 



350 DISEASES OP THE 

Experience has shown that there is a frequent connexion 
between the developement of tubercles in the lungs and white 
swellings of the joints. 

The lesions which we have now enumerated may all be re- 
ferred to three principal sources. 

1. To the same cause which originally produced the tuber- 
cles in the lungs. This cause, reveals itself by the develope- 
ment of tubercles in other organs as well as in the lungs, and 
by the usual train of symptoms which characterize the scrofu- 
lous diathesis. The ancients were well aware of the existence 
of this constitutional taint; and accordingly they divided phthisis 
pulmonalis into the congenital, and the acquired. 
. 2. To the alteration in the process of sanguification which 
must necessarily take place in every instance where the lung, 
filled with tubercles, becomes impermeable to the air through 
the greater part of its extent. 

3. To the repetition of the pulmonary hyperemia in different 
organs. 



CHAPTER IV. 



Lesions of the Innervation of the Lungs, 

We have now enumerated all the morbid appearances which 
have as yet been observed in the organs of respiration. There 
are, however, certain diseases which cannot be referred to any 
of these alterations of structure, which can only be explained 
by attributing them to some derangement of that portion of 
innervation which regulates and presides over the functions of 
the respiratory organs. Let us. take the hooping-cough for 
example : Can the phenomena of this disease be explained by 
the morbid appearances which we find on dissection ? De- 



PARENCHYMA OF THE LUNGS. 351 

cidedly not ; inasmuch as nothing can be more variable than 
than these appearances. In some children, a slight redness of 
the trachea or bronchia is the only morbid appearance to be 
discovered ; in others, the bronchia are dilated, and their par- 
ietes either hypertrophied or thinner than natural ; in others 
we find emphysema of the lungs ; in others, again, tubercles, 
either scattered through the substance of the lung, or else ac- 
cumulated round the principal bronchia. In two cases, 
M. Breschet found the pneumo-gastric nerves red and tume- 
fied ; but no such appearances were ever found by M. Billard, 
who frequently examined the nerves of the eighth pair in 
hooping-cough, without being able to discover any appearance 
of disease in them. 

Of all these different morbid appearances, there is not one 
which can be considered as the cause of hooping-cough. Some 
are purely accidental ; others exist in every species of catarr- 
hal affection ; whilst a third set appear to be rather the effects 
of the disease than its cause. To this class belong emphysema 
and dilatation of the bronchia, which are in all probability pro- 
duced by the violent efforts made during the fits of coughing. 

There are other coughs still more decidedly dependant on 
some modification of the nervous influence ; as an instance of 
which I may adduce the extraordinary varieties of cough we 
so frequently observe in hysterical females. 

There are also several modifications of the voice which can 
only be accounted for by the influence of the nervous system. 
How often do we see persons, when violently agitated, lose 
the natural tone of their voice, or«ven become perfectly inca- 
pable of speaking ! How else than by the disordered action 
of the muscles of the larynx can we account for those piercing 
cries uttered in paroxysms of hysteria ? There is, in fact, in 
these cases, convulsion of the muscles of the larynx, as well as 
of the extremities ; and from their convulsive spasm arises the 
sudden sense of suffocation which the hysterical patient refers 
so distinctly to the larynx. 

Notwithstanding the efforts which modern anatomists have 
made to refer all cases of dyspnoea to an organic cause appre- 
ciable on dissection, there still remain several which they, have 



352 DISEASES OF THE, ETC. 

not been able to trace to any alteration of structure, and which 
must in consequence be referred to a modification of the inner- 
vation ; or, in other words, there are certain cases of dyspnoea 
which must be regarded as nervous diseases.* Our knowl- 
edge of physiology would lead us to this conclusion, even 
though we had not arrived at it by the examination of symp- 
toms, and the result of dissections ; for it has been long ascer- 
tained that, when the par vagum is divided below the laryngeal 
branches, the transformation of venous into arterial blood is at 
once deranged and soon ceases altogether. 



* I have related in my Clinique Medicale several cases of fatal dyspnoea, some 
of which could not be accounted for by any organic lesion, and others which 
were produced by a cancerous tumour that had compressed and disorganized the 
pneumo-gastric nerves. In one of these cases, the patient presented the usual 
symptoms which characterize organic disease of the heart 



THE THYROID GLAND. 353 



SECTION III. 



THE THYROID GLAND. 

The morbid alterations which have been observed in this 
organ are the following. 

1. Acute tumefaction of its substance, produced either by 
an accumulation of blood in its vessels, or by an infiltration of 
serum into its tissue. A similar swelling is sometimes pro- 
duced by making a very violent exertion, in which case it gener- 
ally comes on suddenly. It likewise supervenes as an acute af- 
fection, though not so rapidly, from the use of improper diet. 
M. Coindet of Geneva mentions the circumstance of a regi- 
ment, composed of young recruits, who were almost every man 
attacked with considerable enlargement of the thyroid, shortly 
after their arrival at Geneva, where they all drank water out of 
the same pump. On their quarters being changed, the thyroid 
soon regained its natural size in every instance. 

2. Enlargement from hypertrophy of its substance. This 
hypertrophy may be so very considerable as to produce a lobu- 
lated tumour occupying the entire throat, or even descending 
in front of the chest, and sometimes causing great difficulty of 
breathing. This hypertrophy of the thyroid may appear an 
alteration of structure of but little importance to the mere anat- 
omist ; but to the scientific inquirer, who investigates the causes 
of disease as well as its effects, it is a phenomenon of very con- 
siderable interest ; for he views it not as a mere local lesion, 
but as connected with a profound modification of the whole 
constitution, and as produced under the influence of certain 
causes which operate on entire populations, and in many coun- 
tries render this affection endemic. 

Vol. II. 46 



354 THE THYROID GLAND. 

3. Enlargement from the developement of accidental pro- 
ductions in its interior. These productions are very varied. 
Some are fluid ; such are those substances like serum, honey, 
jelly, or suet, which sometimes infiltrate the substance of the 
thyroid, and are sometimes contained in distinct cells. Solid 
productions are likewise formed in it, the principal of which 
are fibrous tissue, cartilage, and bone. I have seen the thyroid 
transformed into a cyst with osseous parietes, and filled with a 
substance like honey. The cells and cysts filled with gelatin- 
ous fluid so often met with in the thyroid, I consider as merely 
an exaggeration of its natural structure, which consists of a 
number of granules containing a viscid fluid. The first effect 
of hypertrophy is to render these granulations more manifest, 
and to transform them into simple vesicles ; their texture be- 
comes subsequently modified, and at the same time the fluid 
which they secrete is altered in its sensible qualities. 

4. Enlargement from scirrhous degeneration. This occurs 
more rarely than any of the preceding alterations. 

The different lesions which we have now enumerated, are 
generally confounded together under the generic name of goitre: 
but, as many of them are essentially different in their progress 
and termination, it is scarcely possible that the same plan of 
treatment should be equally applicable to them all. Thus, 
iodine, which has lately been extolled as a specific in goitre, 
cannot possibly cure with equal facility all the different varie- 
ties of this affection ; and though it may succeed in reducing to 
their natural dimensions, those enlargements of the thyroid 
which are caused by hypersemia, or hypertrophy, or even by 
the infiltration of serous, melicerous, or gelatinous fluids, it is 
not probable that it can be equally efficacious in dissipating 
those goitres or bronchoceles which are principally composed 
of osseous or scirrhous matter. Another source of error in the 
diagnosis, and consequently in the treatment of this disease is, 
that tumours produced by the thickening of the surrounding 
cellular tissue, or the enlargement of the lymphatic ganglions 
seated in its neighbourhood, have often been mistaken for en- 
largements of the thyroid itself. 



SECRETORY APPARATUSES. 355 



SECRETORY APPARATUSES. 



Every secretory organ may be reduced to a greater or less 
extent, whereby a fluid is separated from the blood. When 
this surface is of small extent, it presents a plane surface ; when 
more extensive, it generally becomes concave, and forms a 
cavity. Sometimes it presents only one of these cavities ; and 
sometimes they become more numerous, and are elongated into 
canals, without, however, ceasing to terminate each in a cul- 
de-sac. This last arrangement is evident in the inferior orders 
of animals, in which certain secretory organs, that form in man 
a homogenous mass, lose the parechymatous appearance, and 
consist merely of an assemblage of canals closed at one ex- 
tremity, as in the liver of insects ; or even of a single duct 
much convoluted, as in the testicle of the ascaris lumbricoides. 

The knowledge of these facts may be of some importance in 
throwing light upon the mode of formation of the organs of se- 
cretion, and the nature of many of their morbid states. 

In the first volume, I have alluded to the influence of exter- 
nal agents in modifying the secretions : and also to the influ- 
ence which the alteration of the simplest, and apparantly least 
important secretion may exert upon the whole system. In this 
way are produced whole classes of diseases, on the cause or 
origin of which morbid anatomy affords no information what- 
ever. Nay more, the very organ whose secretion has been 
deranged, may appear after death free from any appreciable 
alteration. Who could tell, for instance, from examining the 
body of a person who had died of phthisis, that his skin used 
to be bathed in a profuse sweat every day? 



356 SECRETORY APPARATUSES. 

I have already stated, likewise, that the various secretions 
can only be separated from the blood in particular organs, 
adapted to the purpose ; the only exception to this law being 
the perspirable fluid, which is formed wherever there exists a 
particle of matter endowed with life. But, as this fluid is prin- 
cipally formed in the cellular tissue and serous membranes, its 
exhalation appearing to be their chief function, I have judged it 
right to class the diseases of those parts among the diseases of 
the organs of secretion. However, as I have treated of their 
principal alterations in my first volume, I shall merely give a 
rapid sketch of them here. I do not intend, either, to touch 
upon the diseases of the follicles ; as they could not well be 
separated from those of the tegumentary membranes. I shall 
therefore at present only give a detailed account of the diseases 
of the glandular organs properly so called. 



DISEASES OF THE CELLULAR TISSUE, 357 



SECTION I. 



DISEASES OP THE APPARATUSES SPECIALLY ADAPTED TO THE 
SECRETION OF THE PERSPIRABLE FLUID. 



{The Cellular Tissue, and Serous Membranes.) 

The cellular tissue, considered apart from the organs of 
which it forms the framework, and in which it seems to be the 
origin of so many various alterations both of nutrition and se- 
cretion, presents lesions that differ in no respect from those of 
the serous membranes. In fact, what is a serous membrane 
but a large cell of cellular tissue ? 

In eacn, various morbid alterations may occur, either in the 
solids of which they are composed, or in the fluid which they 
contain. The serous membranes are much less frequently al- 
tered in their own proper tissue, than in the cellular layer that 
lines their external surface. 



358 DISEASES OF THE CELLULAR TISSUE, 



CHAPTER I. 



Lesions of the Secreting Tissue. 

In the greater number of cases where the morbid produc- 
tions in the interior of a serous cavity bear witness to the mor- 
bid state of the membrane, its tissue presents no appreciable 
lesion. It is but very seldom we discover in it a few red ves- 
sels, and it is also seldom found thickened ; it somewhat more 
frequently appears softened and friable. 

In many cases where the serous membrane does not present 
any lesion, the subserous cellular tissue is more or less injected, 
a circumstance which frequently, but not constantly, co-exists 
with a morbid effusion into the serous cavity. In others, in- 
stead of mere injection, it presents extravasations and ecchy- 
moses, which sometimes appear to be connected with active 
hypersemia, and sometimes seem to x result from an obstacle to 
the venous circulation. 

The subserous cellular tissue is also occasionally the seat of 
certain alterations of nutrition. Thus, it sometimes becomes 
thickened and indurated, and then appears beneath the serous 
membrane as a white or greyish layer of considerable density, 
which grates under the scalpel, and, when it has attained a cer- 
tain degree of induration, perfectly resembles the scirrhous 
tissue of authors. This alteration is similar to that we have 
already examined in the submucous cellular tissue, and which 
is also observed in the subcutaneous and intermuscular; in fact, 
wherever there exists free cellular tissue. In these various 
parts the lesion is the same, and yet different names have been 
given it ; what has been called scirrhus in the stomach, being 
refused that appellation in the subserous or subcutaneous cellu- 
lar tissue. 

Instead of becoming simply indurated, as in the preceding 
case, it has often a tendency to change its nature, and be trans- 
formed into fibrous or cartilaginous, and eventually into ossse- 



AND SEROUS MEMBRANES. 359 

ons tissue. These transformations have been found on the 
external surface of all the serous membranes. Thus, a great 
part of the convex surface of the cerebral hemispheres has 
been found covered with a cartilaginous or osseous plate ; and 
similar plates have been observed in the falx cerebri and ten- 
torium cerebelli. In the vertebral canal, the subarachnoid 
cellular tissue in contact with the spinal cord is sometimes 
studded with white spots of an osseous, but more frequently 
of a cartilaginous consistence. The pleura costalis has been 
found separated from the ribs for a great part of its extent by 
a cartilaginous or osseous membrane ; and when the lung has 
been thrust back towards the vertebral column by a pleuritic 
effusion, it is not uncommon to find it confined by a layer of 
an osseous or cartilaginous substance, which would oppose an 
insuperable obstacle to its resuming its former bulk, even though 
the effusion were to be absorbed. Cartilaginous or osseous 
plates are also sometimes interposed between the tissue of 
the heart and its investing serous membrane; and the white 
spots that are not unfrequently observed on its exterior are 
likewise situated in the subserous cellular tissue. 

Cartaliginous or osseous transformation does not occur with 
equal frequency in every part of the subperitoneal cellular tis- 
sue. I am not aware that it has ever been observed in the 
cellular layer between the peritoneum and the alimentary canal, 
except in cases of hernia ; but it is by no means uncommon 
around the spleen, on the upper surface of the liver, and the 
lower surface of the diaphragm. Most of the cases of osseous 
transformation of that muscle mentioned in authors, appear to 
me to be merely cases in which one or other of its surfaces 
was lined with a layer of osseous matter.* 



* Dr. Tavernier informed me that, in the body of a man aged sixty, that wag 
examined by M. Goupil and himself, they found in the substance of the right 
portion of the diaphragm an osseo-cartilaginous plate, of an irregularly quadrilat- 
eral form, and of from three to three and a half inches in extent, which was ca- 
pable of being detached from the pleura and peritoneum, and was evidently 
formed at the expense of the muscular and fibrous tissues of the diaphragm, of 
which no trace remained in that part. 



360 DISEASES OF THE CELLULAR TISSUE, 

Lastly, the same transformation has been observed in the 
tunica vaginalis testis. The subserous cellular tissue is likewise 
the seat of several alterations of secretion, of which the follow- 
ing are the principal. 

1. An accumulation of blood, which is sometimes inconsid- 
erable, and does not appear to have produced any unpleasant 
symptoms during life; at other times the haemorrhage is so ex- 
tensive as to constitute a serious disease or even cause the 
death of the patient; thus, some cases of apoplexy are owing 
to an effusion of blood into the subarachnoid cellular tissue of 
the convex surface of the hemispheres. 

2. An effusion of serum around the cerebral hemispheres. 
This, when at all considerable, raises up the arachnoid and 
must tend to compress the brain. It has sometimes a gelatin- 
ous appearance, and sufficient consistence not to flow out on 
an incision being made into the arachnoid. We must not, 
however, forget, that a fluid naturaUy exists round the brain 
and spinal cord, the importance of which has lately been proved 
by Magendie's experiments. This is not the case in the cel- 
lular tissue beneath the other serous membranes ; consequently 
any accumulation of serum beneath them is always the sign of 
a morbid state. I have not unfrequently found some of the 
areolae of the cellular tissue under the pleura filled with a gelat- 
inous fluid. In some cases this was the only lesion present; 
in others there was also thickening, induration, and a larda- 
ceous appearance of the tissue. 

In particular parts of the subserous cellular tissue there nat- 
urally exists a certain quantity of fat. When this is very 
abundant, it pushes the serous membrane before it, and pro- 
jects into its cavity like a kind of fringe. It sometimes ac- 
quires an unusual hardness, and each of its vesicles assumes 
the form of a greyish semitransparent granule, of sufficient 
consistence to resist the pressure of the finger. When these 
vesicles are crowded together, they form considerable tumours 
of a granulated texture, like the tissue of the pancreas. I have 
found tumours of this description in the omentum ; here, again, 
we have another alteration that has been confounded under 
the general name of scirrhus or cancer. 



AND SEROUS MEMBRANES. 361 

4. The subserous cellular tissue is sometimes infiltrated with 
pus. Indeed it is much more frequently in the subarachnoid 
tissue, than in the arachnoid itself, that the purulent matter is 
formed which is found extended in a layer of greater or less 
thickness over the hemispheres of the brain. In the other 
serous membranes, on the contrary, pus is much more fre- 
quently found in their interior than on their external surface. 
The formation of pus generally takes place where the subse- 
rous cellular tissue is most lax. Thus, the only part around 
the pleura where abscesses form, is the anterior mediastinum ; 
and, in the abdomen, the ligamenta lata of the uterus are often 
the seat of purulent collections. 

5. Other morbid secretions also have been found in the va- 
rious portions of the subserous cellular tissue ; melanosis for 
instance : but the morbid production most frequently observed 
in this situation is tubercle, especially in the pleura and perito- 
neum. In the former it is often found in portions of the sub- 
pleural cellular tissue that are considerably thickened. In the 
peritoneum, an innumerable quantity of granular tubercles are 
frequently found studding the surface of the omentum and of 
the peritoneum which lines the abdominal parietes, as well as 
that which is reflected over the viscera. In the subserous 
cellular tissue of the intestines, tubercles are found in large 
quantities in those points which correspond to the intestinal 
ulcers. 



CHAPTER II. 



Lesions of the Fluid secreted by the Serous and Cellular Mem- 
branes. 

Whether any of the various lesions described in the pre- 
ceding chapter exist or not, the cavity of the serous membrane 
Vm TT 47 



Vol. II. 47 



362 DISEASES OF THE CELLULAR TISSUE, 

itself may contain various morbid productions, gaseous, fluid, 
or solid. 

The gases found in the serous sacs, are sometimes secreted 
by the membranes themselves ; but they are much more fre- 
quently introduced from without. Thus, in almost all cases 
of pneumothorax, the gas contained in the pleura is atmospheric 
air, that has entered from the bronchia in consequence of the 
perforation of the walls of a tuberculous excavation situated 
near the surface of the lung. 

The presence of gas in the cellular tissue is also frequently 
the result of a wound in the pulmonary parenchyma, through 
which the air insinuates itself into the whole extent of the sub- 
cutaneous cellular tissue. Occasionally, however, we observe 
instances of spontaneous emphysema, both partial and general ; 
but such cases are rare, and the conditions under which they 
occur are as yet but little known. 

The fluids or solids found in serous cavities are chiefly the 
following : 

1. Serum: its composition is sometimes the same as that of 
the serum of the blood, and sometimes differs from it in con- 
taining either a greater or less proportion of albumen. 

2. The same, combined with a certain quantity of the colour- 
ing matter of the blood. 

3. Pure blood. The peritoneum and pleura are particularly 
subject to these sanguineous effusions. 

4. Pus : this secretion is often found in the cavity of a se- 
rous membrane, without its tissue presenting any perceptible 
lesion 

5. The spontaneously coagulable and organizable matter that 
produces the false membranes. For a description of these, see 
Vol. I. 

I have also pointed out in the first volume the various con- 
ditions under which serum accumulates in the serous cavities, 
as well as in the cellular tissue. I shall merely mention here 
a variety of serous infiltration, long known by the name of in- 
duration of the cellular tissue of new-born infants (skin-bound). 
This is merely the result of an accumulation of serum in their 
subcutaneous and intermuscular cellular tissue. Many of the 



AND SEROUS MEMBRANES. 363 

children come into the world with this affection ; in others, it 
appears a very short time after birth. Other parts of the cel- 
lular tissue are often infiltrated at the same time. Sometimes 
also there is cedema of the lungs. 

This affection is often partial, being confined, for instance, 
to the hands, legs, or feet ; at other times, it is general, and it 
then either commences in one point and gradually involves the 
whole surface of the body, or appears all over it at the same 
time. 

This induration of the cellular tissue of new-born infants is 
generally accompanied by a remarkable state of plethora, the 
principal internal veins being gorged with blood ; the skin is 
often remarkable for its complete want of colour ; in other 
cases, on the contrary, it presents a redness proportioned to 
the general state of plethora ; and in some instances is of a 
bright yellow colour. Of seventy-seven children labouring 
under this affection, M. Billard found thirty affected with 
jaundice. 

The child may die of this affection without any serious 
lesion being discoverable in any organ ; a considerable conges- 
tion in the various capillary networks being all that is observed. 
In general, however, we find some affection of the brain, lungs, 
or alimentary canal, which is to be considered as the principal 
cause of death. 

This affection has been attributed to various organic lesions; 
but, on the one hand, not one of them is constantly present, and, 
on the other, they may all exist without producing it. The 
most constant alteration is a state of general hyperemia of all 
the tissues ; but even this is not invariably present. The skin 
is at the same time very dry and tense, and appears to have lost 
the power of transpiring ; accordingly, in many cases we find 
the cedema disappearing rapidly after the employment of irri- 
tating frictions, and warm applications to the skin, which pro- 
duce an abundant transpiration. It appears, then, that the sup- 
pression of the cutaneous perspiration is a principal agent in 
the production of this disease, and accordingly it occurs most 
frequently in cold seasons, and among the poorer classes, 



364 DISEASES OP THE CELLULAR TISSUE, ETC. 

whose children are least provided against the inclemencies of 
the season. 

We must be careful to distinguish induration of the cellular 
tissue arising from serous infiltration, from that arising from the 
subcutaneous fat becoming remarkably firm and as it were 
congealed. The latter usually takes place only during the last 
moments, or even after death, and its causes are quite un- 
known. 



DISEASES OP THE GLANDULAR ORGANS OP SECRETION. 365 



SECTION II. 



DISEASES OF THE GLANDULAR ORGANS OF SECRETION. 



As it is my intention in this work to treat only of the morbid 
anatomy of those organs the consideration of whose diseases 
belongs strictly to the department of medicine, I shall describe 
in this section only the diseases of the hepatic and urinary or- 
gans. As to the pancreas, I shall content myself with observ- 
ing that it is exceedingly rare to find it altered. I have some- 
times observed it redder than usual, and sometimes remarkably 
firm and compact. In some cases it is found compressed and 
reduced to a state of atrophy by scirrhous and tuberculous 
masses formed around or within it. I once saw the hepatic 
extremity of the pancreas transformed into a hard homogene- 
ous mass of a greyish white colour, in which there was no trace 
of its natural organization perceptible. Another time I found 
it containing two small abscesses, each of which might have 
held a hazel nut. But, in general we may assert that the pan- 
creas is one of those organs in which alterations of structure 
are least common. It is, then, only by hypothesis, that it has 
been made to play an important part in certain gastric affec- 
tions, where the deranged digestion has been attributed to a 
derangement of its secretion. 



366 DISEASES OF THE LIVER 



CHAPTER I. 



Diseases of the Liver and its Appendages. 

These are situated either in the substance of the liver, or in 
its excretory ducts. 



ARTICLE I. 



DISEASES OF THE PARENCHYMA OF THE LIVER. 

If we carefully examine the structure of the liver, we find 
that it is composed of two substances ; one reddish, formed 
chiefly by the ramifications of the capillary vessels of the or- 
gan ; and the other white or yellowish, which seems chiefly 
destined for the secretion of the bile. 

In the natural state, these two substances are distinct ; but 
yet a certain degree of attention is requisite to distinguish them. 
When more blood than usual happens to stagnate in the liver, 
the distinction between them is lost, and the organ presents a 
uniform red colour. When, on the other hand, it contains 
less blood than usual, the yellow substance becomes more ap- 
parent, and in some cases the deficiency of blood is so great, 
that the red substance loses its colour, and the whole of the 
liver presents a whitish tinge. 

These various shades of colour may be owing, 1. to a me- 
chanical obstruction to the venous circulation ; in this case, the 
liver is uniformly red ; 2. to the diminution of the total mass of 



AND ITS APPENDAGES. 367 

the blood ; here the liver appears more or less completely de- 
prived of colour ; 3. to certain affections of the organ itself, 
which affect its circulation, and produce in it a state of hyper- 
emia or anaemia. 

The appearance of the liver may also undergo considerable 
alterations from changes of texture occurring in either of its 
component parts. Thus, the white substance may be affected 
with hypertrophy ; of which there are two degrees. In the 
first the substance of the organ is traversed by lines or circum- 
volutions of a yellowish white colour, which are much more 
distinct than in the natural condition. In the second, both its 
interior and exterior are studded with numerous granules, 
either isolated or agglomerated, and remarkable for their colour 
resembling that of yellow wax. These whitish granules I con- 
sider to be merely the white substance in a state of hypertro- 
phy. Dr. Bouillaud* has clearly proved that an unusual de- 
velopement of the acini of the liver is all that is requisite to 
give it a granulated appearance. In this case, therefore, as in 
the case of the pulmonary granules, there is no necessity for 
supposing the production of any new tissue ; a simple modifica- 
tion in the structure of one of the component parts of the or- 
gan being sufficient to account for them. 

These yellow granules have not always been viewed in this 
light. Laennec considered them as an accidental tissue created 
in the liver, and termed it cirrhosis from its colour. 

While the white substance of the liver is thus preternaturally 
developed, the red may continue in its natural condition, or 
may be altered in its colour, which often becomes very pale 
or olive green ; and in its bulk, which may be either increased 
or diminished. Laennec remarks that cirrhosis is often accom- 
panied by a shrivelled state of the liver. The red substance, 
as it wastes away, becomes infinitely less vascular, and, in cer- 
tain cases, is in a great measure transformed into cellular or 
cellulo-fibrous tissue. This state of the liver is almost constant- 
ly accompanied by ascites. 



Memoirs de la Societd Medicate d' Emulation, vol. ix. 



368 DISEASES OF THE LIVER 

The red substance is likewise susceptible of a very remark- 
able kind of hypertrophy, which produces in the interior of the 
liver small, hard, red massess, that are distinguished from the 
surrounding parenchyma by their greater consistence, and 
deeper colour. These may be unequal in form and size, or 
else distributed through the liver so as to divide it into a num- 
ber of similar lobules. 

Having thus briefly described the alterations which each of 
the two component parts of the liver individually presents, let 
us now turn our attention to the alterations of the entire mass 
of the organ, which we shall find, as usual, to comprise lesions 
of circulation, nutrition, and secretion. 



§ I. Lesions of Circulation of the Liver. 



Hyperaemia is one of the morbid states most frequently pre- 
sented by the liver. It is sometimes general, and the organ is 
then of a uniform red throughout : its volume is increased, and 
its consistence is but little altered, when the affection is simple. 
In many cases, the hyperemia is only partial, forming in dif- 
ferent parts of the organ red spots of various forms and sizes, 
surrounded by a paler parenchyma. 

Hypersemia of the liver is of three kinds. 

The first results from a process of irritation. This irritation is 
sometimes idiopatic, and sometimes subsequent to a similar af- 
fection of the alimentary canal. 

In the second kind the blood accumulates in a manner wholly 
passive in the parenchyma of the organ, just as it does in the 
gums of scorbutic patients. 

The third kind is purely mechanical, being observed where 
there is any obstacle to the free entrance of the blood into the 
right side of the heart ; the blood then stagnates in the supra- 
hepatic veins, and obstructs the liver. 

Congestion of the liver from a mechanical cause is frequently 
produced in infants while coming into the world ; and such of 
them as die in a state of asphyxia have that organ so gorged 



AKD ITS APPENDAGES. 369 

with blood, that it sometimes ruptures its vessels and is effused 
in a layer on its convex surface beneath its investing membranes. 
M. Billard has repeatedly seen an effusion of blood into the ab- 
domen produced by this turgid state of the liver. 

Instead of accumulating in the hepatic capillaries, the blood 
may escape from its vessels, and become effused into the paren- 
chyma of the organ, thus producing a kind of hepatic apoplexy. 
Some of these haemorrhages are owing to the rupture of one of 
the principal vessels distributed to the liver.* In other cases, 
however, there is no perceptible ruptQre of any vessel, all that 
is observed being a collection of fluid or coagulated blood in 
one or more points of the liver. This was well exemplified in 
a liver shown me by M. Rullier, which, besides various collec- 
tions of fluid and semicoagulated blood, contained also some of 
a firmer consistence, in the centre of which were contained 
several hard fragments of fibrine deprived of their colouring 
matter. The examination of this liver led me to inquire 
whether fibrine thus deprived of its colour might not be the 
origin of certain accidental productions, such as encephaloid 
and others, that are often found in the liver ; and my conjec- 
ture received additional confirmation from the examination of 
another liver shown me shortly after by M. Reynaud, in which 
I was able to trace the various changes of the blood from the 
perfectly fluid state until it passed into a substance possessing 
all the characters of encephaloid. 



§ II. Lesions of Nutrition of the Liver. 



Of these lesions, some, such as hypertrophy and atrophy, 
produce a change in the size of the organ ; while others, such as 
softening and induration, only affect its consistence. We must 
take care not to confound increase of size arising from hyper- 
trophy, with that arising from simple hypersemia. 



* Vide Clinique Mfdiccde. 

Vol. II. 48 



370 DISEASES OF THE LIVER 

Hypertrophy of the liver may be divided into several kinds, 
on account of the different varieties of colour, consistence, and 
form, it presents. Thus, with respect to colour, the tissue of 
the liver may be extremely pale, of a much deeper red than 
usual, or of various other tints, such as grey, deep green, or 
brown, which last in some places merges into black. As for 
its consistence, it may either remain in the natural state, or be 
increased or diminished. Lastly, with respect to form, the hy- 
pertrophy may affect all the parts of the organ equally, and thus 
produce no change in that particular ; or, by chiefly affecting 
one of its substances, or being accompanied by atrophy of the 
other, may give it a tabulated, mammillated, or granular appear- 
ance. 

Hypertrophy of the liver may take place in the three lobes 
at the same time, or be confined to one of them. Sometimes 
the right lobe is the one affected, and it then constitutes of itself 
almost the whole organ, the left appearing merely like a small 
appendage attached to it. Sometimes, on the contrary, it is 
the left lobe that is particularly enlarged, and the liver then pro- 
jects considerably into the left hypochondrium, and might some- 
times, when felt through the abdominal parietes, be taken for 
the spleen ; in other cases the projection is observed only in the 
epigastrium, where it might be mistaken for a tumour of the 
stomach. As to the lobulus Spigelii, I cannot confirm from my 
own observation, what has been asserted of the frequency of 
its enlargement without the other lobes being affected. 

The liver of the foetus, and of very young children, is natur- 
ally in a state of hypertrophy, as compared with that of the 
adult. But, as the new-born infant advances in age, the liver 
gradually diminishes in size, ceases to extend into the abdomen, 
and retires behind the ribs, below which it does not again ex- 
tend except when diseased. However, in some cases, this 
kind of natural atrophy does not take place, and the organ re- 
tains during childhood, or even during life, the excess of bulk it 
had at the period of birth : this state of the liver is generally 
connected with other perversions of nutrition which together 
form that particular state termed the scrofulous diathesis. 
Here, then, the hypertrophy of the liver is produced by a cause 



AND ITS APPENDAGES. 371 

which acts at the same time on many other parts, and is in fact 
one of the local signs of an affection really universal. 

Atrophy of the li^er, considered as affecting its substance 
generally, may extend to the three lobes, or be confined to one, 
and may be accompanied by induration or by softening. 

The liver, when in a state of atrophy, is generally diminish- 
ed in size ; this, however, is not necessarily the case, as it is 
sometimes as large as, or even- larger than in the natural state ; 
but then, in proportion as its proper tissue has disappeared, it 
has been replaced by cellular tissue. In such cases the organ 
having lost its peculiar structure and organization is reduced to 
its primative frame-work, and large patches are found in it oc- 
cupied only by cellular tissue, which sometimes becomes hyper- 
trophied, and in some cases contains serous cysts or hydatids, 
which, far from announcing an augmentation of the organic ac- 
tion of the part where they appear, are perhaps connected with 
its diminution ; the cellular tissue, though unable to produce 
the hepatic parenchyma, showing its tendency to organization 
by becoming a serous cyst. 

Induration of the liver has long attracted the attention of 
medical men. It is frequently accompanied by hypertrophy 
or atrophy of the parenchyma ; but it may also exist without 
either. The liver, when indurated, may be of a lighter or 
deeper red, or of a grey, green, or brown colour. 

Softening of the liver is, at least, as frequent as its induration. 
There are two degrees of it. In the first, the diminution of 
consistence of the parenchyma is not perceived until it is press- 
ed between the fingers, when we find that it readily gives way, 
and is reduced to a pultaceous mass. In the second, which is 
much more uncommon, the softening is evident to the eye, the 
tissue of the organ presenting an appearance similar to that 
given it by prolonged maceration: the vascular apparatus is, in 
a manner, dissected from the cellular frame-work, and its ulti- 
mate branches, deprived of their uniting medium, float m a 
red or grey pulp, which seems to be merely the hepatic paren- 
chyma reduced to the fluid state. 

The softened liver sometimes retains its ordinary colour; in 
some cases, it is in a state of hyperemia, and consequently red 



372 DISEASES OF THE LIVEU - 

or brown ; and in others, it is remarkably pale, which seems 
to result from its tissue being modified in such a manner as no 
longer to admit the colouring matter of the blood, of which 
there are no traces to be found except in the large vessels.* 



§ III. Lesions of Secretion of the Liver. 



The experiments of M. Braconnot have proved that the liver 
naturally contains a small quantity of fatty matter; it also se- 
cretes another fatty principle that is met with in other parts of 
the body likewise, and is known by the name of cholesterine. 
Now, if these happen to be secreted in more considerable quan- 
tities than usual, or to be modified in their qualities, they give 
rise to certain morbid appearances in the organ. 

M. Vauquelin has ascertained that there exists in fatty livers 
an oily principle, to which they owe their peculiar appearance, 
and their property of greasing the scalpel. It is easily extract- 
ed from them by boiling, and amounts sometimes only to 
a few drops, and sometimes to such a large quantity as to take 
up more room than the hepatic parenchyma itself. The parts 
of the liver infiltrated with this oily principle are remaikale for 
their pale yellow colour, like that of decayed leaves, and their 
consistence is diminished ; they do not seem to contain any 
blood, or at least there is no trace of its colouring matter to be 
found. The secretion sometimes occupies the whole extent 
of the organ, and sometimes exists only in' some scattered 
points. Instead of being infiltrated through the parenchyma, it 
is occasionally collected in some one spot, being deposited there 
like tubercle or pus, and forming grey or white morbid masses, 
which thrust back the substance of the liver, and present to the 
eye and the touch all the properties of fat. Masses like these 
have been found wholly formed of cholesterine. The causes 
that give rise to this fatty secretion in the liver are as yet un- 
known, it being a mere hypothesis to attribute it to irritation. 

* Vid. Cliniqut Medicale, (Maladies de 1' Abdomen). 



AND ITS APPENDAGES. 373 

I have already had occasion to remark that almost all the 
cases of fatty degeneration of the liver are observed in con- 
sumptive patients, that is to say, in persons whose blood is no 
longer suitably elaborated, and in whom the pulmonary exhala- 
tion cannot be accomplished as in the natural state. Now may 
we suppose, that, because in such persons a sufficient quantity 
of hydrogen ceases to be expelled by the bronchial mucous 
membrane in the form of aqueous vapour, that principle is sep- 
arated in excess from the mass of the blood in the hepatic 
parenchyma, and so produces the fatty matter there? I offer 
this merely as an hypothesis ; but still I think it deserves con- 
sideration, as likewise does the question how far pulmonary 
melanosis arises from a similar defect of elimination of the car- 
bon by the same membrane; and, how far the greater frequency 
of the gravel in cold or damp situations or seasons depends 
upon less azote than usual being removed from the blood 
through the lungs under such circumstances. 

Several morbid productions, that have nothing analogous to 
them in the healthy state, may be developed in the liver. 
Amongst these is pus, which may be found either infiltrated 
through, or forming a collection in it. 

Abscesses of the liver are so rare that some modern authors 
well acquainted with morbid anatomy have questioned the re- 
ality of their existence. In fact, they are exceedingly rare in 
these countries, but are common enough in hot climates, as may 
be seen by perusing the works on the diseases of Europeans in 
India.* 

The pus contained in the liver does not differ from that of 
other parts of the body, neither has it the colour of lees of wine, 
as has been asserted. In every instance in which I found pus 
in the liver, it was of the same colour and consistence as that 
of a phlegmonous abscess. 

Of the purulent collections seated in the liver, some are so 
small as to consist of a single drop, while others, again, occupy 
an entire lobe, and sometimes even almost the whole of the or- 



Vid. Annesly On the Diseases of India. 



374 DISEASES OF THE LIVER 

gan. Occasionally, there are several of these collections, which 
sometimes communicate by fistulous passages, and sometimes 
remain perfectly isolated. The walls of these abscesses are 
often formed of the tissue of the liver itself; in other cases they 
are lined by a cellular or pseudo-mucous false membrane.* 

The pus thus accumulated in the liver endeavours to escape 
from it by different ways ; the following are those that have 
been enumerated as capable of forming outlets for it. 

1. A fistulous passage opened through the skin of the abdo- 
men, ribs, or axilla. 

2. A perforation of the diaphragm and pleura, into the cavi- 
ty of which latter the abscess bursts. 

3. A perforation of the diaphragm, pleura, and pulmonary 
parenchyma, so that the pus is evacuated through the bronchia. 
It is necessary for this, that adhesions should have been pre- 
viously established between the liver and the diaphragm, and 
between the diaphragm and the lungs. 

4. The abscess may burst into the cavity of the peritoneum. 

5. It may burst into some part of the alimentary canal, 
either the stomach, duodenum, or colon. It has been asserted 
that a perfect cure may result from this mode of evacuation. 

6. When near the gall bladder, it may empty itself into it, 
and pass from thence into the biliary duct. 

7. A case is recorded of the communication of an abscess of 
the liver with the interior of the vena cava. 

8. Another is mentioned of its opening into the pericar- 
dium, f 

The cases in which pus has been found in the liver may be 
referred to four classes. The first comprises those in which 
abscesses have been formed in consequence of a spontaneous 
irritation of the organ, whether primary, or subsequent to a 
gastro-intestinal irritation. I have already said that such cases 
are very rare, at least in this climate. To the second, may be 
referred those cases in which the irritation of the liver, instead 



* Louis, JV/emotre sur les abces dufoie, dans la Repertoire tT Anatomic, etc. Gliniqut 
Midicale (Maladies de l'abdornen). 

| Vid. La Clinique des Hdpiteaux, vol. i. No. 71. 



AND ITS APPENDAGES. 375 

of arising from any internal cause, has been the result of some 
external violence that has acted directly on the hepatic region. 
The third comprises those in which the abscess has been pro- 
duced by an irritation arising from some external cause that has 
acted, not on the liver itself, but on the brain. However, the 
question of the formation of abscesses of the liver succeeding 
to wounds of the head requires some farther investigation. 
Lastly, to the fourth class belong those cases in which the pus 
seem to have been carried into the liver in the blood by a 
genuine metastasis. In these cases, at the same time that we 
find one or more purulent collections in the hepatic parenchy- 
ma, without any appreciable alteration of the surrounding tis- 
sue, we meet with similar collections in other parenchymatous 
organs. This may occur in three different cases : 1. where 
there exists a collection of pus in some other part of the body ; 

2. immediately after such a collection has been dried up ; and, 

3. after the establishment of a suppuration in some part of the 
body by a surgical operation. In these three cases, we may 
account for the phenomenon, either by admitting a metastasis 
of the morbid product ; or by supposing that, from the circum- 
stance of pus being no longer formed in a part of the system 
where it had long been secreted, the system, being accustom- 
ed to the secretion, set it up in another part ; or by supposing 
that there are certain individuals in whom suppuration cannot 
be established in any one point of their body, without having a 
tendency to become established in other points also. 

Writers have described by the name of cancer of the liver, 
an alteration of that organ in which certain morbid produc- 
tions distinguished by well marked physical characters are de- 
posited in its parenchyma. They are those that have been 
described in the first volume by the names of encephaloid and 
colloid matter. They produce in the liver masses of various 
sizes, that are sometimes uniformly white, and sometimes 
white mixed with red. Their consistence is not always the 
same, some of them being firmer than the surrounding paren- 
chyma, and others resembling a greyish pap, in the midst of 
which a greater or less quantity of blood is often effused. 
These masses frequently occupy the greatest part of the organ, 



376 DISEASES OF THE LIVER 

leaving scarcely a vestige of its natural tissue between them. 
They occasionally project on its external surface ; and the 
liver then has a knobbed appearance which is sometimes per- 
ceptible through the abdominal parietes. 

It follows from some facts already mentioned, that these so 
called cancerous masses may arise from an effusion of blood, 
which, when coagulated within the substance of the liver, un- 
dergoes the various changes I have described. But, it is far 
from being proved that such is always the origin of these can- 
cerous tumours. In many cases, all that we can discover, is 
at first the infiltration of a minute portion of the parenchyma 
of the organ with a whitish matter, the parenchyma being at 
the same time more or less injected at the point of infiltration 
or around it. This whitish matter gradually becomes more 
abundant, and the proper tissue of the organ no longer displays 
such an appearance of vascularity, though its vessels may still 
be detected by dissection or maceration ; and it is then often 
discovered that the vessels traversing the morbid mass, which 
at first appeared to be vessels of new formation, belong to the 
liver itself. The surrounding parenchyma generally falls into 
a state of atrophy, but it may also become irritated and in- 
flamed, in which case it often secretes pus, or ulcerates, and 
in this way produces a communication between the mass of 
encephaloid and the cavity of the peritoneum or of the intes- 
tine. 

A white friable substance, which is considered to be tuber- 
cle, is sometimes, though rarely, found in the liver; it occurs 
either by itself, or mixed with encephaloid matter, from which 
it maybe distinguished by its different colour and consistence. 
Melanosis is a secretion of still more rare occurrence in this 
organ. 

Lastly, hydatids are frequently found in the liver, contained 
in cysts, which are sometimes so enormous as to occupy al- 
most the whole of the prgan. The walls of the cyst are gen- 
ally composed of fibrous membrane, which may be detached 
from the tissue of the liver without tearing it. The cyst is of- 
ten very near the external surface of the liver, and may even 



AND ITS APPENDAGES. 377 

project above it, and thus become sensible to the touch through 
the abdominal parietes.* 

These cysts may open, 1. externally, through the abdominal 
parietes ; 2. into the cavity of the peritoneum ; 3. into the in- 
terior of the alimentary canal; 4. into the pleura; 5. into the 
bronchia, whence they are expelled by expectoration. 



ARTICLE II. 



DISEASES OF THE BILIARY DUCTS. 

The biliary ducts and gall bladder are liable to various al- 
terations, none of which give rise to any unpleasant symptoms 
during life, unless they produce a diminution of their caliber. 

The lining mucous membrane of the biliary ducts is some- 
times so swollen, from the effects of hyperaemia, as to contract, 
or even totally obstruct the passage of the part affected. I have 
seen cases where jaundice arose from this cause. The source 
of the hyperaemia may either be in the ducts themselves, or in 
the alimentary canal, the irritation spreading from thence along 
the ductus choledochus. 

When the obstruction exists in the ductus choledochus, it 
often happens that the other ducts and the gall bladder become 
dilated ; this may be carried to such a degree as to produce in 
the liver accidental cavities filled with bile. 

When affected with chronic irritation, the walls of the biliary 
ducts may undergo a considerable degree of hypertrophy, their 
cavity at the same time remaining unaltered, or becoming en- 
larged. In some cases, however, the cavity is completely 
obliterated, and the duct transformed into a fibrous cord. This 



* Clinique Medicate. 

Vol. II. 49 



378 DISEASES OF THE LIVER 

alteration has been observed both in the ductus choledochus 
and cysticus. 

When the ducts have been obliterated for a certain length of 
time, the gall bladder, which was at first dilated, contracts, the 
bile is absorbed out of it, and its diminished cavity contains 
only a little mucous matter, or else is completely filled with 
calculi. 

Under the influence of acute or chronic irritation, the walls 
of the biliary ducts sometimes become softened or ulcerated, 
and eventually perforated ; in consequence of which the bile 
escapes into the cavity of the peritoneum. The perforation 
occasionally takes place in some point behind where the duct 
is obstructed. 

The gall bladder presents the same alterations as the ducts, 
its walls being found red, ulcerated, softened, or perforated. 
In this last case, the bile sometimes escapes into the perito- 
neum, and sometimes is evacuated through a perforation in the 
integuments. 

In other cases the walls of the gall bladder are found in a 
remarkable state of hypertrophy, the folds of the mucous mem- 
brane disappear, and a dense cellular substance, like fibrous 
tissue, is interposed between the mucous and the serous mem- 
branes; I think I have sometimes perceived some muscular 
fibres in this situation. 

While the walls of the gall bladder are thus hypertrophied, 
it may itself become considerably enlarged. It may, however, 
become greatly enlarged, so as to extend beyond the thin mar- 
gin of the liver, without its walls appearing at all thickened; 
being merely distended by the accumulation of bile, in conse- 
quence of some obstruction in the ductus choledochus. 

There are two degrees of atrophy of the gall bladder: in the 
first, there is still some little cavity left; in the second.it is 
completely obliterated, and the ductus cysticus terminates in a 
mass of cellular tissue. 

Atrophy of the gall bladder often occurs without any known 
cause. It is sometimes the result of some obstacle to the en- 
trance of the bile into the ductus cysticus : as the reservoir, then 
becoming useless, it has a tendency to disappear, like the thy- 



AND ITS APPENDAGES. 379 

mus, suprarenal capsules, &c, under similar circumstances. 
In other cases, it occurs in consequence of inflammation. The 
reader will find in my Clinique Medicale a remarkable case of 
a person who, some time before his death, passed pus and cal- 
culi through a fistulous opening that formed spontaneously in 
the right hypochondrium, and in whose body there was no ves- 
tige of a gall bladder discovered on examination after death. 

The gall bladder sometimes becomes the seat of various mor- 
bid secretions, which occur either in its interior, where we find 
mucus, calculi, blood, pus, &c, or in the substance of its walls, 
which are not unfrequently infiltrated with serum, or contain 
tuberculous or calcareous matter ; they have sometimes been 
found almost wholly ossified. 

The gall bladder presents some congenital malformations. 
Thus, it is sometimes completely wanting, and the liver then re- 
sembles that of certain animals. In other cases, it is divided 
into several compartments. In others, again, it receives its duct 
directly from the liver, and gives off another which opens di- 
rectly into the intestine. There are also some remarkable va- 
rieties of conformation in the various biliary ducts ; such as two 
ductus choledochi, either both opening into the duodenum, or 
one there, and the other into the stomach ; or the ductus chole- 
dochus opening into the stomach, a malformation which, if we 
are to believe the account of an old author, was in one instance 
accompanied by an habitual bulimia. 



ARTICLE III. 



ALTERATIONS OF THE BILE. 



We cannot establish any connexion between the alterations 
of the liver (such, at least, as we can discover by anatomy) and 



380 DISEASES OF THE LIVER 

those of the bile. In the greater number of the lesions of the 
liver just described, the bile in the ducts and gall-bladder does 
not appear altered either in quantity or quality. In other cases, 
again, where the structure of the liver does not appear at all 
changed, the bile is either excessive or deficient in quantity, or 
altered in its sensible qualities. I have sometimes been aston- 
ished at the immense quantity of this fluid in the intestines, in 
cases where they were but slightly inflamed, and the liver did 
not appear in the least altered. 

The reason of the secreting fluid's being altered without the 
secreting organ's being so, is, that in the liver, as in every other 
organ destined to separate a fluid from the blood, the alterations 
of texture that are apparently the most serious, are not always 
those that exert the greatest influence over the act of secretion ; 
the derangement of this secretion seems to depend rather on 
certain lesions of the organ that escape our observation, and not 
unfrequently on the lesions of other parts. Thus, Magendie's 
experiments have proved that, by changing the food of an ani- 
mal, we can alter at pleasure the composition of the bile, which 
is evidently owing to the previous alteration of the blood from 
the same cause. 

Alterations in the quality of the bile may be discovered, I. 
by simple inspection ; 2. by physiological experiments ; and, 3. 
by chemical analysis. 

We have long been aware, from experiments on animals, 
that the bile taken from some dead bodies, produces no other 
inconvenience when introduced into the living body than an in- 
considerable irritation, while that taken from others produces 
much more serious consequences, and sometimes even death 
itself. In some instances, it may be touched and tasted with 
perfect safety ; in others, it produces pustules, ulcers, &c, on 
the tongue and lips. Here, then, we have very important 
changes in the bile, which we could never have learned from 
anatomy. 

The only alterations in the quality of the bile discoverable by 
inspection, are changes in its colour and consistence. It has 
been observed to have every shade of colour, from the deepest 
black to an almost transparent whitish tint. Its consistence is 



AND ITS APPENDAGES. 381 

also very variable, it being sometimes as thick as pitch, some- 
times like glue, and sometimes fluid as water. 

We learn from chemical analysis that the different compo- 
nent elements of the bile vary greatly in their proportions. 
Sometimes, especially in cases of fatty liver, it is found to con- 
tain scarcely any thing but water and albumen. At other times, 
the yellow matter, the resin, or the cholesterine is the predom- 
inant principle. The causes on which these variations depend 
are as yet unknown. 

It is this change in the proportions of the component parts of 
the bile that produces biliary calculi. These calculi are found 
in three different parts ; 1. in the interior of the liver, where 
they are lodged in the ramifications of the excretory ducts ; 2. 
in the three great ducts (hepaticus, cysticus, and choledochus) ; 
3. in the gall-bladder. This last may contain numbers of cal- 
culi, without giving rise to any appreciable symptom ; while, 
on the other hand, a single calculus lodged in the ductus hepat- 
icus or choledochus may produce jaundice by presenting an 
obstacle to the escape of the bile. 

The size of these biliary calculi is very variable, some being 
like grains of sand, and others as large as a walnut or a small 
hen egg. Their number is generally in inverse proportion to 
their size. Whenever there are many of them together in the 
gall-bladder, they are observed to have facets on them. They 
are sometimes rugged, like the urinary calculi composed of 
oxalate of lime. Their principal colours are white, yellow, and 
black. It is very common to find calculi that are black exter- 
nally, and yellow internally. Some of them have a brilliant 
and semitransparent fracture. 

With respect to their chemical composition, there are five 
varieties of biliary calculi; the first consisting of the yellow 
matter of the bile; the second, of the resinous matter; the third, 
of cholesterine ; the fourth, of picromel ; and the fifth, of phos- 
phate of lime. I have twice found the last mentioned variety 
in the gall-bladder; but in both instances the obliteration of the 
ductus cysticus had long prevented the entrance of any bile 
into it, and the calculus had formed in the mucus it contained. 



382 DISEASES OP THE LIVEB, ETC. 

Instead of bile or matters formed at the expense of that fluid, 
there are sometimes found in its excretory ducts, 1. mucus and 
pus, as has been already mentioned; 2. blood; 3. entozoa; 
these are either individuals of the species ascaris lumbricoides, 
which get there from the intestines, or of the fasciola hepatica, 
which are formed in the ducts themselves. 

It was supposed that the jaundice always arose from some 
obstacle in the biliary ducts to the passage of the bile into the 
duodenum, but this opinion is incorrect, inasmuch as those 
ducts are often found perfectly free in persons that die of the 
disease. Indeed nothing can be more variable than the state 
of the liver in jaundice ; any one of the numerous alterations to 
which that organ is subject, may be attended by it, but none 
of them are constantly or inseparably connected with it. There 
are even cases of icterus where we cannot discover any lesion 
whatever in the liver or its appendages ; and in many such cases 
we have reason to doubt that the liver had any thing to do with 
the disease. We are not to suppose, however, that the yellow 
tinge of the skin can be produced only by the presence of the 
colouring matter of the bile in the blood, as it sometimes seems 
to arise merely from a sanguineous suffusion of its tissue. Such, 
especially, seems to be the nature of the icterus neonatorum, in 
which we can observe the red tinge of the skin gradually 
changing into a yellow, which in its turn fades away, and is 
succeeded by the natural colour of the part. Neither can we 
find in the liver of children that die of this disease any con- 
stant lesion that could account for it. Some have asserted, 
indeed, that in such cases they found the liver gorged with 
blood ; but it is found at least as frequently in the same state 
where there has been no jaundice at all. 



DISEASES OF THE URINARY APPARATUS. 383 



CHAPTER II. 



Diseases of the Urinary Apparatus. 

If we consider the great activity with which this apparatus 
performs its functions, and the constancy of its action, we shall 
find reason to conclude that it ought to be very frequently de- 
ranged. This opinion will be strengthened by observing the 
wonderful rapidity with which every circumstance that is capa- 
ble of affecting the system affects the secretion of urine. There 
is scarcely a disease which does not produce some change in 
it ; and the nature of the food used, the least variation in the 
atmosphere, or even a mere emotion of the mind, are any of 
them sufficient to alter its composition, or influence its excre- 
tion. Yet, notwithstanding all these disturbing causes, the 
organization of the urinary apparatus is not very frequently al- 
tered. In the greater number of diseases, whether acute or 
chronic, we cannot discover by dissection any change in the 
structure of the kidneys; and the rest of the apparatus is in gen- 
eral equally free from lesion; so that we have here another case 
where the functional derangements of an organ are not eluci- 
dated by its structural alterations. 



ARTICLE I. 



DISEASES OF THE KIDNEYS. 



§ I. Lesions of Circulation. 



The kidneys are sometimes found in a state of hyperemia, 
and so gorged with blood that it gushes forth when an incision 



384 DISEASES OF THE 

is made into them. Tins state of congestion may extend to 
both kidneys, or may be confined to one. It may be either gen- 
eral, or partial, or, in other words, may affect both the constit- 
uent parts, (the tubular and the cortical,) of which the kidney 
is composed, or only one of them. In the former case, these 
two substances become confounded together, and cease to be 
so distinct from each other as before. When the kidneys are 
affected with hypersemia in a very high degree, they assume a 
kind of chocolate colour. I once found them in a considerable 
state of hypersemia, without any other alteration, in an individ- 
ual that had died of diabetes. 

Incomplete anaemia is the state in which the kidneys are 
usually observed to be in persons that have sunk under chronic 
diseases. When carried to a high degree, the anaemia becomes 
of itself a disease, but it has not as yet been discovered to pro- 
duce any peculiar derangement of function during life : it is not 
uncommon in dropsical patients, in whom the kidney is often 
remarkable for its extreme paleness, and scarcely contains a 
drop of blood. The whole of the organ may be thus affected 
with aneemia ; or it may be confined to the cortical substance; 
or even to the tubular. Lastly, there are some cases in which 
we find the affection existing only in a few scattered points, 
whose perfect paleness contrasts strongly with the redness of 
the rest of the organ. There are often three or four such 
points in the same kidney, and they are generally situated in 
the cortical substance near the surface. In such cases, when 
we attempt to inject the vessels of the kidney,* we sometimes 
find that the injection penetrates the organ as usual, except in 
the colourless spots, where it stops as if the vessels there were 
obliterated. 

We also find occasionally in the kidneys a deep yellow colour, 
either uniform or spotted with red or white. I am inclined 
to think that this is owing merely to a less advanced degree 
of anaemia. 



Reports of Medical Cases, &c, by Richard Bright, London, 1927, in 4to. 



URINARY APPARATUS. 385 

The kidneys, when in a state of anaemia, are in some cases 
soft and flaccid, and in others unusually firm and indurated, so 
as to give the idea of being converted into cartilage. 

It has been often asserted that the chief alteration observed 
in the kidneys of persons that die of diabetes, is an extreme 
paleness of their tissue. However, I have just mentioned a 
case in which they were, on the contrary, in a state of hyper- 
emia. In another case that fell under my observation, they 
retained their natural appearance. We shall see farther on 
some cases in which the disease was accompanied by hyper- 
trophy of the kidneys. As far as I am aware, there has not 
been a single instance recorded, within the last ten years, of 
the kidneys of a diabetic person being in that state of anaemia 
that has been so insisted upon by some authors. 



§ II. Lesions of Nutrition. 



The kidneys are occasionally found much larger than usual, 
without any other change of structure. This simple hyper- 
trophy may affect but one of them ; and it generally happens 
that when one is wanting, or much smaller than usual, the 
other becomes preternaturally enlarged. I saw a case where 
hypertrophy of one of the kidneys seemed to depend on the 
circumstance of there being two renal arteries at that side. 
M. Lauth, of Strasburg, has recorded a similar instance, in 
which the enlarged kidney, besides its ordinary nerves from 
the semilunar ganglion and lesser splanchnic, received also 
several twigs from the second lumbar ganglion. Hypertrophy 
of the kidneys is one of the most common lesions observed in 
cases of diabetes. 

I think we ought to refer to an exuberance of nutrition, those 
cases of malformation in which the kidneys are united by an 
intermediate substance resembling them in its texture, and 
passing from one end to the other over the vertebral column. 
This kind of middle lobe presents several varieties of arrange- 
ment, being sometimes without any special vessels, and some- 

Vol II. 50 



386 DISEASES OP THE 

times receiving them directly from the aorta and vena cava, 
in which case it sends off a duct resembling a ureter, which 
either runs into the natural ureters, as is generally the case, or 
opens directly into the bladder. 

We find in several authors a description of granulations 
existing in the cortical substance of the kidney, which are by 
some considered as serving to secrete the urine, and by others 
as consisting of a mass of vessels interlaced. Be that as it may, 
similar granulations are sometimes observed to constitute a 
really morbid state. Granulations of the same description are, 
as I have already stated, not unfrequently found in the liver. 
In the latter organ, they evidently result from hypertrophy of 
one. of its anatomical elements ; but, in the kidneys this is by 
no means so certain, their nature being as yet not well under- 
stood. Dr. Bright, who has given an excellent description of 
them, represents them as existing only in the cortical sub- 
stance ; I have, however, seen one case in which the tubular 
substance also contained them. They are small, hard, whitish 
bodies, of various sizes, and of a globular form. Sometimes 
they are few in number, and sometimes they are crowded to- 
gether so as scarcely to leave any traces of the cortical sub- 
stance, and even to occupy the intervals between the cones of 
the tubular substance. In some instances they project beyond 
the surface of the organ, so as to be distinguishable through its 
fibrous tunic ; in others they occupy only its interior. 

In the various cases of this affection observed by Dr. Bright, 
the urine contained albumen, and the patient was dropsical, 
although the heart and liver were sound. I have mentioned a 
similar case in the third volume of my Clinique Medicale, which 
appeared about a year before the publication of Dr. Bright'* 
work. It is difficult to comprehend how this state of the kid- 
neys should produce dropsy, but the fact is certain. 

The kidneys are also subject to atrophy, which may be either 
general or partial. General atrophy of the kidneys is charac- 
terized merely by the diminution of its volume, and may affect 
one or both. In an individual who died at La Charite without 
having ever shown any symptoms of lesion of the urinary pass- 
ages, I found the kidneys exceedingly unequal in size, one of 



URINARY APPARATUS. 387 

them being of the ordinary dimensions, while the other was 
scarcely as large as that of a new-born infant. Its structure 
was natural, but its vessels were much smaller than usual. 

I have seen some cases where the general atrophy of the 
kidney depended on the existence of a tumour in its neighbour- 
hood, or of an abscess formed around it. An instance of this 
kind is recorded in my Clinique Medicate: the tumour, which 
was very large, and contained hydatids, was situated between 
the liver and the kidney, which was completely hidden by iti 
In such cases, it is evident that the atrophy of the kidney is ac- 
cidental, depending either upon the mechanical compression, 
or upon the diminution of activity in the nutritive process in the 
kidney, in consequence of its increase or derangement in the 
surrounding parts. In other cases, as in the one mentioned in 
the preceding paragraph, it is impossible to decide whether 
the atrophy was congenital or accidental. 

Lastly, one of the kidneys may be completely wanting. I 
have seen two cases of this description. The subject of one of 
these was a woman of sixty, in whom there was not a vestige 
of the left kidney to be found, and the left renal artery was also 
totally deficient. However, the left suprarenal capsule was 
well developed ; which shews that its existence does not ne- 
cessarily depend upon that of the kidney. 

The subject of the second case was a young man who en- 
tered the hospital in a state of dropsy, of which the organic 
cause could not be detected. He was carried off by a phleg- 
monous erysipelas of the right femur, which terminated in 
gangrene. The peritoneum was found to contain a quantity of 
limpid serum; there was also some in the pleura and pericar- 
dium; and the whole of the subcutaneous cellular tissue, and a 
great portion of the submucous, were infliltrated with the same 
fluid. The lungs, heart, large vessels, thoracic duct, liver, and 
spleen, were all sound. The urinary apparatus, on the con- 
trary, was remarkably disordered, the right kidney being en- 
larged, softened, and studded with those whitish granulations 
already described ; and the left being totally wanting. Instead 
of the left renal artery, there was an exceedingly small vessel, 
which was lost in the cellular tissue that occupied the place of 



388 DISEASES OF THE 

the kidney. On the internal surface of the bladder, at the point 
where the left ureter usually enters it, was a very small orifice, 
leading into a duct which immediately terminated in a cul-de- 
sac. I did not take any note of the state of the suprarenal 
capsule. 

I have given these cases in detail, because I conceive that 
all the facts mentioned are worthy of notice. We must not 
omit to observe, too, that dropsy was present only in the second 
case, where the kidney that remained was diseased. 

There is yet another case, of more common occurrence than 
the preceding, in which the single kidney is found, not in its 
natural situation, but in front of the vertebral column. In every 
case of this description which I had an opportunity of examining, 
the kidney was only apparently single, being composed of the 
two united and confounded together in the median line, like the 
eyes in cases of cyclopia. 

I know of but one instance of complete absence of both kid- 
neys in the adult, which is that recorded by Klein. It is, how- 
ever, by no means perfectly decisive, as, in my opinion, it seems 
to be rather a case where those organs were in a rudimentary 
state. He says he once found the two ureters terminating at 
their superior extremity in three or four small culs-de-sac, 
which had no renal parenchyma around them. It would have 
been interesting to learn, whether there was any urine secreted 
in this case. 

Even in monstrous foetuses, the kidneys are almost always 
present, though other organs, such as the heart or liver, may 
be wanting. However, Fleishman has recorded a case of 
complete absence of the urinary apparatus in a seven months' 
foetus, which had neither an anus, genital organs, nor inferior 
extremities, while the heart, liver, and alimentary canal, as far 
as the anus, were natural. 

It sometimes happens that there appears at first to be but 
one kidney, from the circumstance of the other being situated 
in the hypogastrium, beside the bladder. I have seen a case 
of this kind: the renal artery was furnished, not by the aorta, 
but by the hypogastric artery; and the ureter, which was very 
short, entered the bladder at the usual situation. The most 



tTRINARY APPARATUS. 389 

remarkable fact in this case is the origin of the renal artery, 
which proves that the point of the circulating system from 
which an artery is given off, has little to do with the develope- 
ment and accomplishment of the functions of the organ to 
which it is distributed. As to the question whether the unusual 
origin of the artery caused the unusual situa ion of the kidney, 
or the reverse was the case, we shall, probably, never be able 
satisfactorily to decide it. 

We now come to the case where the atrophy of the kidney 
is only partial, being confined to one of its substances. As far 
as I am aware, the cones of the tubular substance are never 
affected with atrophy except in such cases as that mentioned 
by Klein ; while the cortical substance, on the contrary, is not 
unfrequently found in a state of atrophy. In such cases, the 
bases of the tubular cones rest on the fibrous tunic of the kid- 
ney, or at most are separated from it only by a very delicate 
layer of cortical substance ; there are also evident depressions 
between the cones, arising from the loss of the cortical sub- 
stance. 

The kidneys are likewise subject to softening and induration. 
The former is often accompanied by hyperemia ; their co-ex- 
istence may be considered as conclusive evidence of inflamma- 
tion ; and this conclusion drawn from dissection may be con- 
firmed by the symptoms observed during life. Thus, I have 
sometimes found the kidneys intensely red, and almost pulpy, 
in the bodies of persons who, some time before death, had felt 
pain in the lumbar region, and had passed bloody or purulent 
urine. I met this same red softening in the highest degree in a 
man whose kidneys contained large calculi. I have also found 
it accompanying various chronic alterations of the bladder, 
such as thickening and brown coloration of its mucous mem- 
brane, puriform secretion of its follicles, &c. 

There is another kind of softening, in which the substance 
of the kidney is remarkably pale, or of a peculiar grey tint. I 
have observed this in cases where there had not been the least 
symptom of disease of the urinary passages. Its nature and 
causes are as yet unknown. 



390 DISEASES OF THE 

Induration of the kidney, like its softening, is of two kinds ; 
one attended with hyperemia, and the other with blanching of 
the tissue. The first kind is generally accompanied by a state 
of hypertrophy of the organ ; the second may likewise be ac- 
companied by enlargement of the kidney, but, in most cases, 
its bulk is diminished. The white induration of the kidney 
presents two degrees : in the first, it is firmer than ordinary, 
but retains its natural structure ; in the second, which seems a 
more advanced stage of the first, its tissue is so condensed, hard, 
and white, as to resemble cartilage. I have sometimes found 
this second degree of induration confined to two or three of the 
tubular cones. 



§ III. Lesions of Secretion. 



Under this title I comprise the various productions that seem 
to be deposited in the parenchyma of the kidney, by a process 
resembling that which produces the perspiratory exhalation in 
every living particle. The alterations of the urine, therefore, 
do not belong to this class. The morbid productions at present 
under consideration are as follows. 

1. Serum. We not unfrequently find in the cortical substance 
small cysts with serous parietes, which adhere but slightly to 
the tissue of the kidney, and contain a limpid colourless fluid. 
These cysts sometimes become enormously developed, and the 
parenchyma of the organ wastes away proportionably, so much 
so, that we occasionally rind the whole interior of the kidney 
occupied by a large serous sac, the cavity of which is generally 
divided into several compartments. This transformation seems 
to be produced rather by a diminution of the natural activity 
of the nutritive process, than by irritation. The same may be 
said of those cases where I have found masses of condensed 
cellular tissue in the kidney, corresponding to an evident de- 
pression on its surface. 

2. Fatty matter. On opening some kidneys, I have found that 
their cortical substance, which was pale or yellow, evidently 



URINARY APPARATUS. 391 

greased the scalpel. The cause of this morbid alteration is 
unknown, but it seems to depend principally on some special 
predisposition in the individual to the secretion of fatty matter. 

3. Purulent matter. It has long been known that abscesses 
may be formed in the kidney. They are sometimes but of 
small extent, and the surrounding parenchyma is scarcely al- 
tered; in other cases, the whole organ is converted into a sac 
filled with pus, which is generally multilocular, and may exceed 
in bulk the kidney itself, and thus produce a tumour distinguish- 
able through the abdominal parietes. In other cases, on the 
contrary, the kidneys, when transformed into a purulent cyst, is 
at the same time singularly diminished in bulk ; but this occurs 
only when it is surrounded by a collection of pus situated in the 
cellular tissue, or when it is bound down by false membranes 
produced by a partial peritonitis. When the sac is multilocu- 
lar, the septa often consist of a hard, lardaceous tissue. 

The pus thus formed in the kidney may pass off by the ure- 
ter, or may burst into the cavity of the peritoneum, or may 
communicate through the loins with the surface of the body. 
The abscess has also been known, in some few cases, to open 
into the colon. 

In certain cases, the pus, instead of forming a collection in 
the kidney, merely infiltrates its substance, producing in it a 
number of whitish spots, from which a puriform matter may 
be extracted by pressure. These whitish spots have often 
been mistaken for masses of tubercle, and described by that 
name. This kind of infiltration often co-exists with the pres- 
ence of purulent collections in other organs, or in the veins. I 
have seen several instances of this, but shall select only one. 
A boy, aged sixteen, had a large abscess in the right iliac fossa. 
On dissection, I found a whitish mass in one of the kidneys, 
which was evidently nothing but the tissue of the organ infil- 
trated with pus. Another remarkable case of the same kind 
is to be found in the Journal Hebdomadaire, Vol. n. p. 75. 

4. Colloid or gelatiniform matter. I once found the whole 
of the cortical substance of the kidney transformed into a mat- 
ter resembling a strong jelly or solution of starch. There 



392 DISEASES OF THE 

had not been any sign of disease of the urinary passages during 
life. 

5. Encephaloid matter. This morbid production has often 
been observed in the kidney, where it sometimes forms small 
masses that produce no alteration either in the form or in the 
size of the organ, and sometimes considerable tumours, that 
greatly increase its size. I once saw a case in which one of 
the kidneys was almost wholly transformed into encephaloid 
matter, and had become at least as large as the right lobe of 
the liver. The tumour thus formed appeared during life to 
occupy chiefly the left hypochondrium, and had been mistaken 
for a tumour of the spleen. 

Encephaloid matter is often found in the kidneys, without 
appearing in any other organ ; this, however, is not always the 
case. It sometimes seems to be deposited in the substance of 
the organ, and sometimes is found lodged in its small vessels. 
Thus, in two cases of kidneys that contained masses of ence- 
phaloid, I found that the renal vein contained a coagulum, 
which was in some points remarkably friable, and in others 
like sanious pus. Pursuing the dissection farther, I found 
most of the ramifications of the vein filled with the same mat- 
ter, and at last discovered that what I had taken for a morbid 
mass developed in the substance of the proper tissue of the 
kidney, consisted merely of a number of small vessels contain- 
ing this altered blood. We have already seen, that such is 
also the nature of many of these masses in other organs, the 
lungs, liver, and spleen, for instance. This case, therefore, be- 
ing analogous, is the more important, and affords additional 
confirmation to what has been suggested respecting the nature 
of encephaloid matter. 

6. Tubercular matter is not often found in the kidneys ; and, 
when it is, generally exists in other organs also ; indeed I re- 
collect but one instance to the contrary. Tubercles of the 
kidneys may be developed, 1. in the cortical substance ; 2. in 
the tubular substance ; and, 3. in layers, immediately around 
the calices and pelvis. I am not aware of any case on record 
of tubercles being formed in the parenchyma of the kidney, 
and subsequently making their way through the walls of the 



URINARY APPARATUS. 393 

pelvis, and passing off with the urine ; but I can conceive 
such a case occurring. 

There is sometimes found in the kidneys, either by itself, or 
mixed with other morbid productions, a white substance of va- 
riable consistence, which, though strongly resembling tubercle, 
does not appear to be of the same nature as the substance to 
which that name is usually applied. It occurs, however, but 
seldom, and its nature is not understood. 

7. Entozoa. The only entozoa ever found in the human 
kidneys are hydatids, which have been observed in some few 
cases, and the strongylus. The latter, however, though com- 
mon enough in animals, especially in the dog, is exceedingly 
rare in man. 



ARTICLE II. 



DISUSES OF THE EXCRETORY PASSAGES OF THE URINE. 



These may be situated in the calices, the pelvis, the ureters, 
the bladder, or the urethra ; but, as the diseases of the last 
mentioned part belong exclusively to surgery, I shall give but 
a slight sketch of them here. 



§ I. Diseases of the Calices, Pelvis, and Ureters. 



The mucous membrane of these parts sometimes becomes 
congested ; there is often nothing else but this hyperemia to 
be discovered, where the patient had been passing purulent 
or bloody urine, accompanied with pain in the region of the 
kidneys, and in the course of the ureters. 
Vol. II. 51 



394 DISEASES OF THE 

The same membrane may likewise become thickened, either 
throughout its whole extent, or in some parts only ; and this 
alteration may produce a temporary or even permanent oblit- 
eration of the ureters. In one instance, I found in the pelvis of 
the kidney a soft, red, fungous tumour, with a broad base, and 
about the size of a small walnut which seemed to be merely a 
vegetation from its mucous membrane. 

M. Louis mentions a remarkable case in which the walls of 
the calices, pelvis, and ureters were of more than twice their 
natural thickness, and their capacity nearly doubled, while the 
kidneys themselves, which were remarkably pale, were re- 
duced to half their ordinary dimensions. 

The mucous membrane in this situation may, as in other 
parts, secrete pus without necessarily being ulcerated. I have 
seen it covered with a thick layer, like the false membrane of 
croup. M. Louis mentions a case where the whole of the in- 
ternal surface of the ureters was lined with a layer of tubercu- 
lous matter, which was also found in the pelvis, and in the par- 
enchyma of the kidney, as well as in the lungs.* 

The calices, pelvis, and ureters are capable of becoming ex- 
tremely dilated, when there is any obstacle to the free passage 
of the urine into the bladder. The ureters are often found re- 
markably dilated in various affections of the uterus, in which 
the cavity of the bladder is diminished by the formation of 
tumours around it. On the other hand, when the obstacle to 
the passage of the urine is situated near the kidney, the portion ' 
of ureter below it contracts, and may even become obliterated. 

We sometimes observe cases of malformation of the ureters. 
Thus, they have been found united by a transverse duct. 
Again, two ureters may pass from the same kidney, and either 
open separately into the bladder, or unite before entering it ; 
the latter is generally the case. 

When the bladder is wanting, or exists only in a rudiment- 
ary state, the ureters terminate in some other part. Thus, 



Iiecherch.es stir la phthisic, p. 129. 



' URINARY APPARATUS. 395 

they have been known, in such cases, to open into, 1. the um- 
bilicus ; 2. the rectum ; 3. the vagina ; 4. the urethra. In 
many of these cases, the diameter of the ureters has been found 
wonderfully increased, as if for the purpose of supplying the 
place of the bladder. The same is sometimes observed in the 
biliary ducts, when the gall-bladder is wanting. 



§. II. Diseases of the Bladder. 



This organ is very seldom found diseased in persons that die 
of any acute or chronic disease except those of the urinary 
passages. I make this assertion from my own observation, and 
it is confirmed by the late researches of M. Louis ; since, in 
five hundred subjects, he found the mucous membrane of the 
bladder injected only in six cases, and ulcerated in but one, in 
which the man had died of typhus fever. It is singular how 
seldom any part of the urinary apparatus is found altered in 
persons dying of this disease, considering how frequently they 
suffer from retention of urine. 



A. Lesions of Circulation. 

The mucous membrane of the bladder, when in a state of 
hypersemia, may present various shades of colour ; sometimes 
it is traversed by an infinite number of minute vessels which 
give it a bright vermilion hue, which may be either generally 
diffused over its surface, or appear only in detached patches, or 
lastly, in small distinct points. When we examine these points 
attentively, we find that each consists of a red circle surround- 
ing a white space with a small depression in its centre. This 
kind of injection appears to belong to the follicles, and re- 
sembles one of the varieties of injection of the intestinal follicles 
already described. 



396 DISEASES OF THE 

Another kind of colouring, that is sometimes observed in 
cases of chronic affection of the bladder, is where the internal 
surface is of a brown or even black tint. This colour, is gen- 
erally accompanied with thickening of the coats, and, in every 
instance that came under my observation, appeared to result 
from chronic irritation of the part. 

Authors have said a great deal about a varicose state of the 
veins of the bladder. I am inclined to think that such an af- 
fection is at least much more uncommon than has been repre- 
sented. 



B. Lesions of Nutrition. 



These may affect any one of the coats of the bladder singly, 
or all of them together. One of the most common is hyper- 
trophy, which I shall in the first place consider as it exists in the 
mucous membrane. 

Hypertrophy of the mucous membrane of the bladder is 
characterized by a more or less considerable augmentation of 
its thickness, while, at the same time, it either retains its nat- 
ural colour, or becomes red, grey, brown, or black. The af- 
fection may be only partial, producing in the interior of the 
bladder a variety of tumours, vegetations, and fungous ex- 
crescences, that resemble those we have already described as 
arising from a similar cause in the intestines. These tumours 
present considerable varieties of texture ; some of them con- 
sisting of a hard, homogeneous tissue, apparently destitute of 
vessels, others, of a soft and highly vascular tissue, while others 
are formed by a mere prolongation of the natural membrane, 
so that this portion of the mucous membrane, like all others, 
presents two varieties of hypertrophy, one in which its sub- 
stance is thickened but its texture not altered, and another in 
which its texture no longer retains its natural character. 
M. Louis, in his Recherches sur la Ph.th.isie, has described a 
very singular lesion of the mucous membrane of the bladder, 
which resembles that at present under consideration, only so 



URINARY APPARATUS. 397 

far as that there were tumours on the internal surface of the 
organ ; but, it would be very difficult to determine its real 
nature, the case being quite anomalous. 

The interesting researches of M. Gendrin have pointed out 
the remarkable peculiarity of the mucous membrane of the 
alimentary canal being the only one furnished with villi, or at 
least, the only one that exhibits them distinctly. I am, how- 
ever, inclined to think that the other mucous membranes are 
not really destitute of villi, but that they are only very slightly 
developed, from the circumstance of their becoming distinctly 
apparent in certain morbid states of those membranes. We 
have already seen an example of their appearing on the mucous 
membrane of the air passages ; and we owe to M. Louis an in- 
stance of the same thing occurring in the bladder. The case I 
allude to is that of a person who had, for six years, been affect- 
ed with hsematuria, without pain in the hypogastrium, or ema- 
ciation. On examination after death, M. Louis found the inter- 
nal surface of the bladder lined with a tissue that floated when 
put into water, and divided into numerous filaments of from 
four to seven lines in length, of a fine red colour, and closely 
crowded together, except in some points where they formed 
isolated tufts. Now, I think these were evidently villi in a 
state of hypertrophy. 

In the healthy state, the follicles of the bladder are scarcely 
more apparent than the villi ; but in the morbid state they also 
may be enlarged, and become very distinct. They then ap- 
pear as small round bodies, variously coloured, and often fur- 
nished with two vascular zones, one round their basis, the other 
round the margin of their central orifice : in short, they per- 
fectly resemble the intestinal follicles. They are found thus 
greatly developed chiefly in persons who had been passing 
urine strongly loaded with a mudous or purulent matter, for 
some time before death. 

The submucous cellular tissue is perhaps more frequently 
affected with hypertrophy and induration than the mucous 
membrane itself. When the hypertrophy is inconsiderable, it 
has no other effect than to produce a slight increase of thick- 
ness in the walls of the bladder; when greater, and at the same 



398 DISEASES or THE 

time circumscribed, it forms tumours that project into the in- 
terior of the organ, and gradually increase to such a size as to 
occupy its whole cavity. 

This same affection may occur in the other cellular layers 
around the bladder. Thus, some of those hard tumours, called 
scirrhus, which diminish the capacity both of the rectum and 
of the bladder, originate in the preternatural developement and 
induration of the cellular tissue situated between those organs. 
The same may happen in the cellular tissue which separates 
the bladder from the genital organs in females. 

The muscular tunic of the bladder may likewise be affected 
with hypertrophy ; when this alteration is confined to a certain 
number of its fasciculi, it gives the internal surface of the organ 
that peculiar appearance that has procured for it from French 
writers the name of vessie a colonnes. There is a peculiar vari- 
ety of this affection in which the hypertrophied fasciculi are 
disposed exactly like the columnce carnece in the heart. 

In the various cases already mentioned, the hypertrophy 
of the bladder is the result of disease ; there, are others where 
it appears to be congenital, namely, where we find preternatural 
septa in the interior. These septa are sometimes imperfect, 
and sometimes so extensive as to divide the cavity into two or 
three compartments. They are often situated in the median 
line, thus forming, as it were, two bladders, each of which re- 
ceives a ureter. In some cases each compartment opens di- 
rectly into the urethra; in others, only one communicates di- 
rectly with it. These compartments not unfrequently contain 
calculi. They are sometimes termed supernumerary bladders ; 
but that name more properly belongs to those pouches that are 
occasionally appended to the bladder, with which they com- 
municate by an aperture, and with whose parietes theirs are 
continuous. I once saw a pouch of this description as large as 
a hen egg. These, also, may contain calculi. 

The bladder is likewise subject to various degrees of atro- 
phy some of which are accidental, and others congenital. The 
atrophy sometimes consists merely in the walls of the organ 
being thinner than usual ; this arises principally from the im- 
perfect developement of the muscular coat, which may even 



URINARY APPARATUS. 399 

be completely deficient for a considerable space, and permit 
the mucous membrane to form a hernia through the opening 
thus formed. 

Instead of the walls of the bladder being merely attenuated, 
a portion of them may be completely wanting. It is almost al- 
ways the anterior portion that is deficient ; and' there is at the 
same an imperfect developement of the abdominal parietes, 
which are open from the umbilicus to the pubis ; in some cases', 
the ossa pubis also remain separate ; and in others, besides the 
malformations already mentioned, the genital organs are either 
absent, exist only in a rudimentary state, or are badly formed. 
The corpora cavernosa, for instance, may be separate through- 
out the whole extent, the upper part of the canal of the urethra 
may be open, <fcc. 

The individuals in whom the anterior wall of the bladder is 
wanting, present the malformation known by the name of ectro- 
pia vesica. This consists of a red tumour of mucous appear- 
ance, situated at the bottom of the abdomen, in the place usually 
occupied by the linea alba and recti muscles or symphysis pubis, 
and having its margin continuous with the skin of the surround- 
ing parts. There is a constant trickling of the urine from two 
points in this tumour, which is merely the posterior wall of the 
bladder. 

I have already spoken of those cases in which the bladder is 
totally absent, and mentioned the various parts where the ure- 
ters then discharge their contents. 

The mucous membrane of the bladder is sometimes greatly 
diminished in its consistence. M. Louis has found it quite soft 
without any appearance of increased vascularity or other alter- 
ation, either in itself or in the other coats of the bladder. 

Sometimes all the coats are so completely softened that the 
slightest pull is sufficient to tear them ; a spontaneous perfora- 
tion may even take place in this way during life. 

Lastly, the bladder, like all other hollow organs, is subject to 
ulceration. The ulcers may either be confined to the mucous 
membrane, or may extend deeper, and perforate the parietes 
of the organ. The urine then, in some cases, escapes into the 
peritoneum, in others, makes its way directly out of the body 



400 DISEASES OF THE 

through a fistula, and, in others, passes through the rectum or 
vagina. It often happens that the ulceration commences in 
one or other of the two parts last mentioned, and extends sub- 
sequently to the bladder. 



C. Lesions of Secretion. 



These may exist either on the free surface of the mucous 
membrane, or beneath it. 

The mucous membrane may secrete four kinds of fluid, 
namely, mucus more or less altered in quantity or quality, 
blood, pus, and a matter which concretes and forms a false 
membrane on the internal surface of the organ. I have seen 
two cases of this last kind of morbid secretion, which resembled 
the false membranes of the air passages. 

In the substance of the walls of the bladder, we occasionally 
meet with pus, tuberculous matter, encephaloid, and melanic 
matter. In one instance, I found a serous cyst, of the size of a 
walnut, beneath the mucous membrane. 



§ III. Diseases of the Urethra. 



Some of these lesions are congenital, amongst which are the 
following. 

1. The stoppage of the canal of the urethra. The cause of 
this may reside either in the prepuce or in the urethra itself, 
from the agglutination of its parietes, or from the presence of a 
membrane that, like a diaphragm, interrupts its continuity. 

2. A preternatural opening in the urethra, the usual orifice 
being at the same time present or not. This malformation in 
some cases consists of a simple orifice situated under the glans. 
In others, it is more considerable, extending like a groove along 
the whole of the inferior surface of the penis, or being even 
continued under the scrotum. If at the same time the testicles 



URINARY APPARATUS. 401 

have remained in the abdomen, and the penis is small and im- 
perforate like a clitoris, the sides of the divided scrotum then 
resemble labia, and the result is an appearance of hermaphro- 
dism. 

At the same time that the urethra presents some one of these 
malformations, it often happens that the urachus is preserved, 
and the urine passes out by the navel. This duct has also been 
known to persist where there was no other malformation ap- 
parent. 

Of the lesions of the urethra that occur after birth, there are 
some that depend on a simple modification of the capillary cir- 
culation of its mucous membrane. Thus, it is found red, but 
generally without any trace of ulceration, in persons who hap- 
pen to die while they have a running of purulent matter, what- 
ever be its origin. I must add, however, that in some cases of 
this affection, whether recent or of long standing, the mucous 
membrane of the urethra exhibits no redness on examination 
after death. In like manner, when a person dies while labour- 
ing under sore throat, it often happens, as Bichat remarked, 
that the pharynx, though red during life, appears pale after 
death ; and in cases of a chronic discharge from the intestines 
or bronchia, I have in more than one instance found the mu- 
cous membrane of the alimentary canal or air passages per- 
fectly white.* 

The urethra is subject to certain lesions of nutrition in its 
mucous membrane and subjacent tissues, the usual effect of 
which is to produce various degrees of narrowing of its duct. 

The principal lesions of nutrition that affect the mucous 
membrane are, 1. thickening ; 2. vegetations or excresences 
(Morgagni, Swediaur) ; 3. warty granulations (Hunter); 4. 
cicatrices of ulcers (Dupuytren) ; 5. fraena extending trans- 
versely or obliquely from one side of the parietes of the canal 
to the other; 6. enlargement of the mucous follicles ; 7. preter- 
natural dilatation or other alteration of the lacunae. 



+ CliniqueMedicale. 

Vol. II. 52 



402 DISEASES OF THE 

Those that occur beneath the mucous membrane are chiefly 
varieties of thickening and induration of the submucous cellular 
tissue. 

In all these various cases, a simple contraction may be con- 
verted for a time into a complete obliteration, by a temporary 
hyperaemia of the mucous membrane. 



§ IV. Alterations of the Urine. 



This fluid presents many varieties of appearance which be- 
long more properly to the department of semeiology, and con- 
sequently do not come within the plan of this work. We are 
to direct our attention at present to the great changes it may 
undergo in its composition, which may be reduced to three 
classes. 

The first class comprehends those cases where there is mere- 
ly a change in the proportion of the natural constituents of the 
urine. 

The second, those in which there are new principles added 
to the urine, but still such as are found in the blood either in 
the healthy or diseased state. 

Lastly, the third class comprehends those cases where the 
new principles added to the urine are not to be found in the 
blood. 

I shall devote a distinct article to each class. 



A. Alteration of the Urine from a Change in the Proportion of 
its Constituents. 

Of all the constituents of the urine, the water is that whose 
proportion is most variable. As long as this variation is con- 
fined within certain limits, it is compatible with a good state of 
health ; but beyond those, it constitutes disease. There are 
some individuals in whom, either constantly or at intervals, the 
urine is almost solely composed of water and a very small 



URINARY APPARATUS. 403 

quantity of animal matter ; this is the chemical characteristic 
of diabetes insipidus. 

The urea may also present considerable variations in its pro- 
portion. It often exists in much greater abundance than 
natural ; this may easily be discovered by its being precipitated 
in unusual quantities by the addition of an equal part of nitric 
acid to the urine. In such cases, there is an increased activity 
in the secretion of the urine, which has been mistaken for di- 
abetes. 

In other cases, on the contrary, the quantity of urea pro- 
duced is very small. It has been long supposed, from the re- 
sults of former analyses, that this principle is not to be found 
in the urine of diabetic patients. However, the late researches 
of M. Barruel * have proved that this is, at least, not invariably 
the case, as he found some urea in urine that contained sac- 
charine matter also ; so that the presence of the one does not 
necessarily exclude the other. 

Most chemists maintain that the urine naturally contains a 
certain quantity of free uric acid ; while M. Prout thinks that 
it is in combination with ammonia. Be. that as it may, there 
are certain morbid states, in which this acid certainly exists in 
the urine in the free state, and in such quantity as to be pre- 
cipitated in the solid form. Gravel almost always consists of 
uric acid ; and several calculi are also composed of it. 

There are other cases where there is not a trace of uric acid 
to be found in the urine ; as in diabetes, the chemical charac- 
teristic of which disease appears to be more constantly the ab- 
sence of that acid than of the urea. 

The causes that influence the production of an excess of uric 
acid in the urine have lately been elucidated by M. Magendie, 
in his Recherches sur la Gravelle; I have already treated of 
them in other parts of this work. 

The lactic acid, which M. Berzelius asserts to be one of the 
components of urine, has not been hitherto found altered 
in its proportion. This is not the case, however, with the 
phosphoric acid. According to M. Prout, it is in consequence 



* Journal de Chimie Medicate. 



404 DISEASES OF THE 

of this acid's not being formed in sufficient quantity, that the 
salts of which it is the base are transformed into neutral and 
sub-salts, and then precipitated ; and hence is the origin of the 
calculi composed of phosphate of lime, or of the ammoniaco- 
magnesian phosphate. 

The alkalies that enter into the composition of the urine, 
namely, potash, soda, lime, and ammonia, may be formed in 
excessive quantities ; this produces no inconvenience in the 
case of either of the two former ; but when it is the lime that 
is in too great quantity, the salts it forms with the phosphoric 
acid are precipitated ; and, when it is the ammonia, there is 
also a precipitation of the earthy salts, which were previously 
kept in solution. 



B. Alteration of the Urine by the Addition of new Principles, 
that are found in the Blood. 



These principles are of two classes, according as they are 
constituents of the blood, or occur only accidentally in that 
fluid. 

Those of the first class are albumen, fibrine, and the col- 
ouring matter of the blood. 

The urine in its natural state does not contain the least trace 
of any of these principles ; but in certain morbid conditions 
they are found in it either singly or together. 

The presence of albumen in the urine is easily detected by 
the application of heat, which causes it to coagulate. Albu- 
minous urine is generally pale, and sometimes opalescent when 
viewed immediately on being passed. Dr. Bright states, that 
the presence of albumen in the urine is one of the symptoms 
which indicate a granular state of the kidneys. 

The kidneys may also secrete fibrine from the blood. 
M. Prout saw a remarkable instance of this in a woman aged 
thirty, who had a voracious appetite, but was otherwise in 
good health. Her urine consisted almost wholly of a semifluid 
mass of a pale yellow colour, which was composed of a se- 



URINARY APPARATUS. 405 

rous part, and of a solid part which had all the characters of 
the fibrine of the blood. 

It has been asserted that in certain kinds of dropsy the 
urine contains a great quantity of fibrinous matter. Now, does 
the cause of such dropsies consist in the alteration of the func- 
tions of the kidneys? Can it be that the subtraction of a 
quantity of fibrine from the blood by means of those organs, 
produces this tendency to the formation of serous collections 
in every part of the body 1 If so, it acts like venesection, 
which, when too copious, or too often repeated, also disposes 
to dropsy by withdrawing the fibrine from the blood. 

As to the colouring matter of the blood, it may be mixed 
with the urine either in the kidneys, or in the bladder, in which 
latter it is exhaled by the mucous membrane. Exhalation of 
the colouring matter of the blood often results from irritation 
of the kidneys or bladder, and is then symptomatic of a purely 
local lesion. In other cases, however, it is merely one of the 
phenomena of a general morbid condition, in consequence of 
which the blood has a general tendency to escape from its ves- 
sels ', as in scurvy, certain forms of typhus, &c. 

The principles of the second class are either foreign bodies 
(chiefly colouring or odorous matters) that have entered the 
blood by the stomach or lungs, and are got rid of by the kid- 
neys, or else the elements of various secreted fluids that have 
remained in the blood or re-entered it, and afterwards pass 
out alone with the urine. The principle of this latter descrip- 
tion most frequently observed in the urine is the yellow mat- 
ter of the bile ; it has been asserted that caseous matter has 
also been found in it. 



C. Alteration of the Urine by the addition of New Principles 
that are not to be found in the Blood. 



These are chiefly the following : — 

1. Acids. Amongst these is oxalic acid, which seizes on the 
lime contained in the urine, and forms with it a particular spe- 



406 DISEASES OF THE 

cies of calculus. In some cases mentioned by Prout, Magen- 
die, and Ratier, the formation of oxalic acid in the urine was 
evidently owing to the immoderate use of sorrel as an article 
of food. In other cases, the cause of its formation is unknown. 
Berzelius thinks it results from an increased activity in the 
functions of the kidneys, which according to him consist chiefly 
in a process of acidification. 

Brugnatelli asserts that he has found hydrocyanic acid in the 
urine. 

2. Oxides. Of these there are two, which have nothing 
analogous to them in any other part of the system : they have 
received the names of cystic and xanthic oxides. 

3. Colouring matters. The black tint sometimes observed 
in the urine has been attributed by Prout to the presence of 
melanic acid ; and the red tint to that of purpuric acid. The 
urine has occasionally been observed to have a blue tinge, and, 
in one case of this description, M. Julia Fontenelle,* detected 
hydrocyanate of iron in it. 

4. A saccharine matter, like the sugar of grapes. The 
presence of this matter is the chemical characteristic of dia- 
betes mellitus. It was formerly supposed that when this mat- 
ter occurs in the urine, it is to be found in the blood also ; but 
more recent researches seem to prove the contrary : I think, 
however, the question is not yet settled conclusively. The 
causes that influence the secretion of this substance are still 
unknown. 

5. A fatty matter. M. Prout found, in one instance, a sub- 
stance like butter in the urine. 

6. Hair. The remarkable fact of the occasional occurrence 
of hairs in the urine, which was long since pointed out by some 
of the older medical writers, has been put beyond all doubt by 
the cases lately published by M. Magendie.* I saw, myself, 
one of the two cases he mentions. A great number of small 
hairs, varying in length from a line to upwards of an inch, were 



* Archives de Medecine, vol. ii. page 104. 
| Recherches sur la gravelle, 2d edition. 



URINARY APPARATUS. 407 

mixed with a white powder, which was found to be composed 
of a great deal of phosphate of lime, a little phosphate of mag- 
nesia, and some traces of uric acid. The subject of the case 
was an old man, who was accustomed to a temperate mode of 
life. According to M. Magendie, he used to pass nearly a pint 
of the mixture of saline substances and hairs every day. The 
other patient mentioned by Magendie used to void with the 
urine concretions covered with hairs. 

Amidst these various alterations of the urine, the kidneys may 
either present some one of the lesions already described, or ap- 
pear perfectly sound, notwithstanding the alteration in the fluid 
they secrete. The reason of this is, that the cause of its modi- 
fication very frequently exists, not in the secreting organs, but 
elsewhere, as in the state of the blood, or of the innervation, in 
the assimilative functions, or in the qualities of the air and food ; 
none of which it is evident are appreciable on dissection. 

The various changes in the composition of the urine above 
enumerated, produce also various changes in its physical prop- 
erties. In some cases they leave its fluidity and transparency 
unaltered ; in others, they render it turbid, or give it an unu- 
sual colour ; and, in others, they form in it solid bodies, which 
are called gravel when in grains, and calculi when concreted 
in masses of various sizes. These calculi are found, 1. in the 
calices and pelvis ; 2. in various parts of the ureters ; 3. in the 
bladder ; and, 4. in the urethra. 

The elementary substances that have been hitherto found 
either single or combined in urinary calculi, are eleven in num- 
ber, viz. uric acid, urate of ammonia, phosphate of lime, ammo- 
ni&co-magnesian phosphate, oxalate of lime, silica, cystic oxide, 
xanthic oxide, a mucous substance, a fibrinous substance, and 
hair. 



408 DISEASES OF THE 



APPARATUS OF GENERATION. 



As a great many of the diseases of this apparatus belong to 
the pathology of the exterior, I shall notice them in a very cur- 
sory manner, the plan of this work allowing me to dwell only 
upon such lesions as are connected more particularly with the 
pathology of the interior. 



SECTION I. 



DISEASES OF THE MALE GENITAL ORGANS. 

I shall just give a rapid sketch of these lesions as they affect 
the several component parts of those organs. 

Besides the hypersemia accompanied with more or less of tu- 
mefaction that is often observed in the testicle, it is subject also 
to certain alterations of nutrition and secretion, which will best 
beunderstood by following them successively through the vari- 
ous investing membranes to the substance of the organ itself. 

1. Cutaneous envelope of the testicle. The most remarkable 
alteration presented by this part is a considerable induration "of 
its tissue, succeeded by ulceration ; this is the disease known 
by the name of chimney-sweepers' cancer. 

2. Dartos. This cellulo-fibrous layer occasionally undergoes 
alterations similar to those we have so often studied in the va- 
rious portions of the cellular tissue subjacent to the different 
membranes. Thus, it may become thickened, or indurated, 
may secrete coagulable lymph, pus, or tubercle, and may, in 
consequence of any of these alterations, form tumours which 
have often been mistaken for an affection of the proper sub- 



MALE GENITAL ORGANS. 409 

stance of the testicle. Many cases of sarcocele appear to con- 
sist merely of some of these alterations of the dartos. 

3. Tunica vaginalis. This, being a serous membrane, is 
subject to the same lesions as the rest of its class. Thus, in the 
disease termed hydrocele, we find it containing a collection of 
serum, without being itself appreciably altered. In some cases, 
the cause of this collection of serum cannot be accounted for; 
in others, it consists either in an obstacle to the free return of 
the venous blood along the spermatic cord, or in some organic 
lesion of the testicle itself; just as tubercles in the brain often 
produce hydrocephalus. There has been sometimes found in 
the fluid of hydrocele a small quantity of cholesterine, in the 
form of brilliant yellow scales : this is an interesting fact, as it 
proves that the secretion of that substance is not confined exclu- 
sively to the liver. The fluid is not always pure serum, being 
often turbid, flocculent, or purulent. The surface of the tunica 
vaginalis is occasionally covered with membraniform layers, 
and adhesions are often formed in different parts of it. 

4. Tunica albuginea. This membrane plays an important 
part in some diseases of the testicle, being sometimes found to 
be the only part affected, in cases in which, during life, the ex- 
istence of a hard, uneven, and painful tumour of that organ, had 
led to the supposition that its parenchymatous structure was 
diseased. In such cases, the membrane is sometimes merely 
in a state of hypertrophy and induration, and sometimes carti- 
laginous, and in some points, even osseous. It is probable that 
in this case, as in others where a fibrous lines a serous mem- 
brane, that the alterations apparently seated in the former mem- 
brane are in reality situated in the intermediate cellular tissue. 
Such, for instance, is the situation of certain abscesses that are 
sometimes found beneath the tunica vaginalis, pushing back 
the tissue of the testicle without involving it. I once found a 
layer of tuberculous matter thus interposed between the two 
tunics ; and in another instance, I found a calculous concretion 
of the size of a nut in the same situation. In the greater num- 
ber of cases where there is any alteration either of the albu- 
ginea or of the cellular tissue that unites it to the tunica vagin- 
alis, hydrocele is produced, but it is generally slight. 

Vol. II. 53 



410 DISEASES OF THE 

5. Parenchyma of the testicle. The principal alterations that 
have been discovered in this are : — 

A. A simple state of hyperemia with more or less tumefac- 
tion. 

B. Grey or white induration of the parenchyma, the tubuli 
seminiferi still remaining visible. 

C. The same kind of induration, the tubuli having disappear- 
ed. The testicle then loses all traces of its primitive organiza- 
tion, and becomes a hard homogeneous mass. This induration 
is sometimes general, and sometimes only partial : in the latter 
case it is often confined to the epididymis. 

D. Encephaloid masses in the substance of the testicle, with 
all possible degrees of induration or softening. 

E. The developement of an accidental erectile tissue, which 
sometimes occupies only some isolated points of the organ, and 
sometimes involves the whole of it. I have already given in 
detail the case of a man who died at La Charite, a few months 
after having undergone the operation of castration for an erec- 
tile tumour of the testicle, and in whose lungs I found a num- 
ber of tumours of the same description. 

F. Collections of pus, which, in some cases are unaccompa- 
nied by any other lesion, and in others are merely the result of 
the alterations already described. 

G. Tuberculous matter. This occurs in the testicle in all 
its varieties of form; sometimes it is hard, and exists in the 
form of a number of minute grains, or of one large mass which 
projects from its external surface ; and sometimes it is softened 
and transformed into a fluid matter, which endeavours to effect 
its escape through fistulous openings in the investing tunics of 
the organ. ' 

M. Reynaud has informed me that he lately discovered in a 
testicle a number of small hard semi-transparent granulations 
resembling those found in the lungs ; a fact which would lead 
us to conclude that the pulmonary granulations may arise from 
some other cause than chronic induration of the air vesicles. 
The subject, however, requires farther investigation. 

The principal alterations of the vas deferens are, obliteration 
of its canal, dilatation of the same with or without thickening 



MALE GENITAL ORGANS. 411 

of its parietes, the existence of purulent fluid in its interior, and 
the formation of a layer of tuberculous matter on its external 
surface. I saw a case of the last mentioned alteration, in a man 
whose testicle was full of tubercles. It is probable that, in the 
organ itself, the tuberculous matter was deposited on the out- 
side of the tubuli seminiferi. 

The vesiculae seminales are sometimes imperfectly devel- 
oped. Meckel mentions instances of there being but one. 
Tuberculous matter has been found in their parietes, and they 
occasionally contain pus and calculi. In some instances there 
is an accidental communication established between them and 
the interior of the bladder. 

The prostate is often enlarged without exhibiting any other 
alteration than simple hypertrophy of its tissue. This hyper- 
trophy may be general, or confined either to one of its lateral 
parts, or its middle portion (the middle lobe of Sir E. Home). 
In other cases, the enlarged prostate loses its natural appear- 
ance, and becomes a homogeneous mass, which is then said to 
be scirrhous. We often find in it fibrous, cartilaginous, or os- 
siform bodies, resembling those found in the uterus. In many 
cases of suppuration of the prostate, all the symptoms of severe 
fever have been observed, although there was no lesion of the 
stomach or intestines.* 

As to the various lesions of the penis, they have been al- 
ready so frequently and minutely described, that it is quite 
unnecessary to recapitulate them here. 



Clinique Mtdicale. 



412 DISEASES OF THE 



SECTION II. 



DISEASES OF THE GENITAL ORGANS OF THE FEMALE. 



CHAPTER I. 



Diseases of the Uterus. 



Of the lesions discovered in this organ on dissection, there 
are some that belong specially to the province of surgery or 
midwifery, such as the various displacements of the body or 
neck of the uterus, and certain alterations of conformation, 
which are generally congenital. Of these I shall give but a 
very summary description here. 

1. Obliquity of the uterus. This may exist without any 
known cause ; in other cases it results from adhesions formed 
between the uterus and lateral parts of the pelvis. 

% Retroversion of the uterus. The fundus of the organ is 
then directed downwards and backwards, and its neck upwards 
and forwards. This occurs most frequently during pregnancy. 

3. Anteversion of the uterus, — exactly the reverse of the pre- 
ceding. 

4. Inversion of the uterus. This lesion consists in the or- 
gan's being turned inside out; there is always at the same time 



FEMALE GENITAL ORGANS. 413 

a greater or less degree of prolapsus of its body, which in some 
cases only projects slightly beyond the cervix uteri, and in 
others appears without the vagina: the tumour thus formed 
presents no orifice, which distinguishes it from that formed by 
a simple prolapsus. Inversion of the uterus happens only 
when its cavity is distended at the same time that its parietes 
are diminished in thickness; hence it generally occurs during 
delivery, or in those cases where accidental productions of 
considerable size are developed in its cavity. 

5. Prolapsus uteri. In this lesion, the uterus protrudes 
through the vagina, and forms a tumour between the thighs, in 
which the orifice of the neck is almost always discoverable. 
Its most common cause is inversion of the vagina. 

6. Hernia of the uterus, whether empty or gravid. 

7. Bilocular state of the uterus. Of this there are several 
varieties. In the first, the uterus has two horns or lobes, as in 
many of the mammalia; and its neck is divided by a septum 
into two compartments, each terminating in its respective lobe. 
In the second variety, the septum is absent, but the lobes re- 
main. In the third, there are no lobes, but the cavity of the 
organ is divided into two by a septum which terminates near 
the neck. Lastly, in the fourth variety, the bilocular state of 
the uterus is only apparent, being produced by a groove in its 
upper margin on the median line ; and the interior of the organ 
presents no sign of division. The septum described in the 
first three varieties may be continued into the vagina, even to 
its external aperture, and is then composed of a doubling of the 
mucous membrane. 

This malformation of the uterus does not prevent the full 
developement of the foetus. One woman in whom it was found 
had had a child, which had come to the full time, but died in 
comiiv into the world. Another, whose case is recorded by 
M. Ollivier,* after having had two dead and two living children, 
became a fifth time pregnant, and, when she arrived at the 
full period of her pregnancy, was suddenly seized with symp- 



* Archives de Mtdecine, vol. vm. p. 215. 



414 DISEASES OF THE 

toms of acute peritonitis, under which she sunk. On examin- 
ation, it was found that the lobe that contained the fetus had 
burst. 

8. Imperfect developement of the uterus. Of this, also, there 
are several varieties. In one of these, half of the organ is 
wanting, and there is at the same time but one ovary, and one 
fallopian tube. In a case of this description observed by 
Chaussier, the woman had had several children, who all came 
to their full time. In another variety, the uterus is so small 
that it requires some attention to find it, the vagina merely 
terminating in a small, hollow swelling, into which open the 
fallopian tubes. In another, again, the neck of the uterus, 
which is of the natural size, is much larger than the body of the 
organ. M. Lauth, of Strasburg, mentions a case of this de- 
scription, in which the fallopian tubes opened almost immedi- 
ately into the neck, being separated from it only by a small 
cavity with thin membranous parietes. There was merely a 
rudiment of the ovaries to be found. The pelvis and the mam- 

' mae resembled those of a man. 

9. Complete absence of the uterus. A case of this was late - 
ly discovered at the Hbtel-Dieu, by M. Dupuytren, in a woman 
aged twenty-seven. The vagina did not exceed an inch in 
length, and behind the cul-de-sac in which it terminated, the 
rectum only was to be found. Above and behind the bladder 
were found the ligamenta lata, containing as usual the fallopian 
tubes and the ovaries, which were both well formed. Where 
the two tubes met, there was a small tumour which had nei- 
ther aperture nor cavity, and bore no resemblance whatever to 
the uterus. The mammas were well developed, the external 
genital parts well formed, and there was nothing masculine in 
the appearance of the woman. She had never menstruated. 

10. Obliteration of the various orifices of the uterus. We 
sometimes find the uterine orifices of the fallopian tubes com- 
pletely stopped up. This arises in some cases from the con- 
tinuation of the mucous membrane over these orifices ; in 
others, from the presence of a particular membrane which 
closes them ; and in others, from the obliteration of the tubes, 
for the extent of a few lines. The neck of the uterus may 



FEMALE GENITAL ORGANS. 415 

likewise be closed, either from the stoppage of its vaginal or 
uterine orifice by a membrane, or from the agglutination of its 
parietes. In some cases, while the two orifices of the neck 
are diminished in size, its cavity is enlarged, or at least retains 
its natural dimensions. 

We are now to turn our attention to those alterations of the 
uterus which belong more particularly to the pathology of the 
interior. 

Hyperaemia of the uterus is sometimes observed unattended 
by any other lesion of the organ. It may occupy its whole 
substance, or be confined to its internal surface. In the latter 
case, the mucous membrane that lines the uterine cavity be- 
comes highly vascular, and separates from the subjacent tis- 
sue, so as to afford ample proof of the existence of such a 
membrane. 

After puberty, the uterus becomes every month the seat of 
hyperaemia which soon passes away without producing any 
unpleasant effects. In some females, however, each return of 
this monthly hyperaemia, is attended with pains in the region of 
the uterus, and often with some degree of fever. But when 
the hyperaemia, instead of resulting from the laws of physiol- 
ogy, supervenes as a morbid affection, the sympathetic de- 
rangement becomes much more serious, although the hyperae- 
mia is not more considerable in the latter case than in the 
former. Thus, in many women that die shortly after their 
delivery, of acute peritonitis, which has evidently arisen from 
irritation of the uterus, we cannot discover any thing in that 
organ but a redness (and that often but slight) either of its sub- 
stance, or else merely of its internal surface. In other cases, 
however, most serious effects are produced ; and the tissue of 
the uterus becomes tumid, changes its consistence, and sup- 
purates. 

Tumefaction of the body 'or neck of the uterus at first 
arises from sanguineous congestion, and may disappear 
along with the congestion, or remain after it. In the latter 
case, the uterus, at the same time that it retains its increased 
size, becomes either indurated or softened ; for both of these 
effects may arise from the same cause. 



416 DISEASES OF THE 

Induration of the uterus takes place very slowly ; while, on 
the contrary, its softening may occur in a short space of time. 
It often happens that, in women who die in a very few days 
after presenting symptoms of irritation of the uterus, its walls 
are found so much softened as to be readily perforated by the 
finger ; indeed, they sometimes become so very soft as to rup- 
ture spontaneously, especially when the uterus is gravid. 

While the tissue of the uterus thus loses its consistence, it 
sometimes becomes the seat of suppuration. The pus may 
either be infiltrated through it, or collected into one or more 
abscesses of various sizes, from that of a pea to that of a wal- 
nut. In some cases the whole tissue of the uterus seems as if 
it were steeped in pus. When these collections are more lim- 
ited, the portion of tissue which surrounds them in some cases 
retains its usual firmness ; sometimes it is of a bright red, or 
violet colour, and sometimes greyish, yellowish, or even re- 
markably pale. 

The pus may be situated either in the substance of the ute- 
rus, or in its cavity. In the former case the suppuration may 
take place either in the parenchyma of the organ, or in its 
veins, which are then so much dilated as to be mistaken for ac- 
cidental cavities. A great number of veins of the uterus are 
sometimes found thus filled with pus ; these convey it into the 
neighbouring vessels, and it is not unusual in such cases to find 
it also in many of the hypogastric veins, in the vena cava, and 
in the parenchyma of various organs, where it is deposited in 
its passage with the blood from the uterus through the various 
parts of the venous system. 

Pus is more seldom found in the cavity of the uterus than in 
its substance. In the greater number of these cases, it appear- 
ed to me that the progress of the morbid processs that pro- 
duced it had not been acute ; indeed, in some cases, there had 
not been any symptoms observed that could be referred to the 
uterus or its appendages. Such, for instance, was the fact, in 
the case of an old woman who died of phthisis at La Charite, 
without having ever complained of any thing that could lead to 
the suspicion of the organs of reproduction being diseased; and 
in whom, notwithstanding, we found the uterus filled with pus, 



FEMALE GENITAL ORGANS. 417 

and its interior lined with a whitish, membraniform layer, be- 
neath which the mucous membrane was highly vascular. 

Such are the principal lesions of the uterus that result from 
acute irritation. Let us now turn our attention to those which 
either result from chronic irritation, or occur without any dis- 
coverable previous irritation. 

Amongst these is softening; but it appears in a very differ- 
ent form from that just described as accompanying acute hy- 
pereemia of the uterus. It sometimes happens that, on exam- 
ining the bodies of women who have died of some diease quite 
unconnected with the uteru?, we are greatly surprised to find 
that organ remarkably pale and flaccid. It may be torn as 
easily as the tissue of the spleen, and in some parts is even 
transformed into a kind of semifluid pulp. This softening is 
sometimes partial, and sometimes general; in which latter case 
the parietes of the organ are often remarkably attenuated. As 
to the cause of this affection, we are quite in the dark: irrita- 
tion and atony are equally hypothetical. All we can say of it 
is, that it bears a great resemblance to similar affections already 
described in the heart, liver, stomach, and kidneys, the cause 
of which is equally inexplicable. 

There is, again, another kind of softening of the uterus, which 
generally attacks its neck, and transforms its tissue into a black 
and fetid putrid mass. This putrid softening is sometimes the 
only lesion to be discovered in the uterus; it may occupy, 1. a 
few lines only of the outer extremity of the neck; 2. the whole 
neck ; or, 3. a certain portion of the body. In other cases it 
supervenes at a certain stage of ulceration of the neck of the 
uterus, or takes place around encephaloid masses formed in its 
substance. 

The uterus is also subject to ulceration in various parts. 
One of the varieties of the disease known by the name of cancer 
of the uterus is merely ulceration of its neck, occurring without 
being preceded by any of those accidental productions termed 
scirrhus and encephaloid. The only preceding affection is a 
tumefaction of the neck of the uterus, which in many cases is 
very slight, though it is sometimes so considerable as to pro- 
duce inequalities and protuberances on its external surface, as 
Vol. II. 54 



418 DISEASES OF THE 

well as on that of the vagina. When the ulceration has once 
commenced, it may either remain stationary for an indefinite 
period, or extend its ravages, and destroy the whole of the 
neck, or even extend to the body of the organ. A superficial 
ulcer of the neck of the uterus is often attended with very se- 
vere pain, while a very destructive one may be almost com- 
pletely indolent. 

Ulcers of the neck of the uterus and of the vagina, especially 
the latter, may burrow so deep as to produce a perforation 
of those parts as well as of the rectum or bladder. Hence 
arise those vesico-vaginal or recto-vaginal fistulas, that are so 
common in cases of cancer of the uterus. 

There is another variety of cancer of the uterus, in which 
the ulceration is only consecutive, and whose anatomical char- 
acter is the developement of encephaloid matter in the sub- 
stance of the organ. This matter may be deposited, 1. in the 
neck alone; 2. in the body, the neck remaining perfectly 
sound; 3. in both these parts at once; 4. in the cellular tissue 
that unites the uterus to the surrounding parts, especially the 
rectum and bladder. In this latter situation, we often find it 
forming large tumours around the cervix uteri and vagina, 
which press upon the rectum or bladder, and sometimes pro- 
ject so considerably into the bladder, that its cavity is almost 
completely obliterated ; in such cases, the ureters are generally 
found greatly dilated. The developement of encephaloid is 
much more common in the neck than in the body of the uterus, 
the latter being often perfectly sound, while the former is dis- 
tended by immense masses of this accidental production, some 
of which have been found of such enormous size as to be five 
or six times larger than the whole organ itself. 

The morbid production just described cannot exist in the 
uterus without producing the most serious derangements in the 
whole system ; and death is, inevitably, the ultimate result. 
There is, however, another accidental production which has 
long been confounded with the preceding, though differing from 
it both in its anatomical characters, and in its comparative 
harmlessness : I mean that which forms the fibrous tumours of 
the uterus. While a mass of encephaloid of scarcely the size 



FEMALE GENITAL ORGANS. 419 

of a walnut would be productive of the most dangerous effects, 
the fibrous tumours may even exceed in size the or^an itself, 
without producing pain, alteration in the general nutritive pro- 
cess, or, in a word, any sympathetic affection whatever. 

Fibrous tumours present the same structure in the uterus as 
in the other parts of the body. They are composed of fibres 
rolled up and matted together ; these bundles of fibres are di- 
vided into several lobules separated from each other by loose 
cellular tissue in which the blood-vessels run. Such is the 
commonest form of these tumours, but it is not uncommon to 
find them conjoined with others which are likewise denominat- 
ed fibrous tumours, though in reality they have no fibrous struc- 
ture whatever, being composed of a number of granules sur- 
rounded each by a layer of cellular tissue, and divisible into 
still smaller grains possessing each a similar investment. The 
appearance of these tumours bears a strong resemblance to that 
of the pancreas. They present three principal varieties of col- 
our, namely, a reddish, a white, and a yellowish tint. As to 
size, they are very variable, some of them being no larger than 
a pea, and others surpassing in size the head of a full grown foetus, 
and thus forming a tumour which in some cases projects into 
the vagina, and in others may be discovered through the walls 
of the abdomen. Their form is generally globular, but their 
surface is occasionally studded with small knobs or marked 
with deep fissures. Their number is indeterminate, there 
being sometimes but one, and sometimes several scattered 
through the substance of the organ ; in the latter case, we of- 
ten find similar tumours in the ovaries, and even in the liga- 
menta lata. 

These fibrous tumours are not all of the same density. Some 
of them are soft, and to a certain degree compressible ; others 
are much harder, and cannot be cut into without difficulty. 
When this induration advances a little farther, the tumour be- 
comes cartilaginous in some points, and osseous, or, more 
strictly speaking, calcareous, in others. This transformation 
generally commences in the centre of the tumour ; and the sur- 
rounding tissue then assumes a remarkable yellowish tint. It 



420 DISEASES OF THE 

afterwards gradually spreads to other parts, and sometimes, 
though rarely, involves the whole tumour. 

With respect to their situation, fibrous tumours of the uterus 
may be divided into three classes. 

Those of the first class are situated outside the uterus, be- 
tween it and its peritoneal covering. These never grow at 
the side next the uterus, and consequently compress it but 
slightly, all their increase of bulk being in the direction of the 
abdomen. 

Those of the second are situated in the substance of the 
uterus. They always grow towards the surface of its parietes 
to which they are nearest ; but, if they happen to be lodged in 
the centre, it is remarked that they remain much longer sta- 
tionary than when situated near either surface. They are 
much more frequently found in the body of the uterus than in 
its neck. 

Those of the third class are developed between the internal 
surface of the proper tissue of the uterus and its lining mucous 
membrane, which then becomes more distinct than in the nat- 
ural state, by being detached from the subjacent parts. As 
they increase in size, they continue to push this membrane be- 
fore them, invest themselves in it, and project into the interior 
of the cavity of the uterus, and sometimes even into the vagina. 
At last, they often cease to be in contact with the walls of the 
uterus, being attached to them only by the investing mucous 
membrane, which is lengthened out so as to form a kind of 
stalk or pedicle. This mucous pedicle, which exists only in 
some cases, may be broad or narrow, several lines in length or 
very short, and furnished or not with distinct vessels. 

The three classes of fibrous tumours just described are all 
united in the same manner to the tissue of the uterus, namely, 
by very loose cellular tissue, so as to be capable of being re- 
moved with the greatest ease, without injuring the substance 
of the organ. When they are of moderate size, the organ con- 
tinues in every other respect the same as in the healthy state ; 
but when they become larger, they alter both the size and text- 
ure of the organ. The bulk of the uterus often becomes very 
considerable in those cases where the tumours are developed 



FEMALE GENITAL ORGANS 421 

on its internal surface, its cavity then enlarging as if it contain- 
ed a fetus ; and at the same time the tissue of the organ as- 
sumes the same appearance as it does in the gravid state. As 
to the mucous membrane, it is sometimes pale, and without any 
appreciable alteration, and sometimes more or less vascular 
In cases where there were several fibrous tumours in the uterus', 
I have occasionally found its cavity filled with fluid or partly 
coagulated blood, beneath which the mucous membrane was 
merely somewhat redder than ordinary. 

These tumours are not formed in the uterus with equal fre- 
quency at all ages. They are rarely met with before the age 
of thirty; while they are very common in old women. Bayle 
has calculated that in every hundred women who die after 
five-and-thirty, there are at least twenty who have these uterine 
tumours ; it is thought that they occur most frequently in those 
persons who have not had children, or have remained un- 
married. 

We occasionally meet with serous cysts of various sizes in 
the walls of the uterus, especially about the cervix, where they 
sometimes exist in hundreds, and project into the interior of the 
organ. 

Tuberculous matter is sometimes found in the same situation. 
This, however, occurs but very rarely, and mostly in cases 
where it is also deposited in many other organs. 

The various morbid productions just enumerated are all situ- 
atued beneath the mucous membrane of the uterus, and, con- 
sequently, on the outside of its cavity. But there are others 
situated within its cavity, which arise from a morbid condition 
of its lining membrane. We have already seen that the mucous 
membrane is capable of secreting pus, and also a substance 
which concretes on its surface, and thus forms a layer that 
sometimes presents traces of organization. Besides these how- 
ever, we find attached to its internal surface certain morbid 
productions, which all agree in adhering to it more or less 
closely, but differ greatly both in their origin and in their inter- 
nal structure. 

With respect to their origin, they are of two kinds ; some 
having been at first merely a coagulum of blood, that gradually 



422 DISEASES OF THE 

assumed a determinate form and organization, and others ap- 
pearing to result from an alteration in the nutrition of the 
membrane itself. In certain cases it is easy enough to distin- 
guish between these two kinds of production ; but, as they ad- 
vance, they come to resemble each other, so as to be at last dis- 
tinguishable only in theory. 

With respect to their form and structure, they generally ap- 
pear as polypous vegetations projecting from the internal sur- 
face of the uterus. 

Many of these polypi appear to be mere prolongations of the 
mucous membrane, of which they assume all the varieties of 
appearance. They are sometimes very short, and in some in- 
stances are of such a length as to reach from the fundus of the 
uterus into the vagina. In some cases their free extremity 
contracts adhesions with some point of the parietes of the cer- 
vix uteri or vagina, thus they become fixed at both ends. They 
are sometimes only as thick as the mucous membrane from 
which they grow, and sometimes much thicker; in like manner 
they may be equally soft with that membrane, or else much 
harder. Again, they may be slightly vascular, or may contain 
such a number of vessels as to present the appearance of an 
erectile tissue. This excessive vascularity is often confined to 
their free extremity, the other remaining like the mucous mem- 
brane from which it arises. 

There are other polypi of a much more complicated struc- 
ture. Some of these consist of a reddish mass containing cells 
of various shapes filled with different fluids. In an elderly 
woman, I found a polypus of the size of a walnut, composed of 
a white, semi-cartilaginous substance, divided into a great 
many cells, which contained another substance resembling 
thin colourless jelly. It was attached to the uterus by a very 
narrow stalk. The cervix uteri was full of small cells contain- 
ing the same jelly-like substance. In another woman, aged 
sixty-six, I found the fundus of the uterus occupied by a reddish, 
and very vascular body, of about the same size as the one just 
described. It was closely adherent to the mucous membrane, 
and presented a great many cells filled with a colourless and 
slightly viscid serous fluid. The parietes of these cells consist- 



FEMALE GENITAL ORGANS. 423 

ed of numerous filaments or laminae, some red, and others of a 
dead white colour, and fibrous texture. In other cases, instead 
of a tumour intersected with cells, we find distinct cysts, that 
are merely attached to each other by cellulo-vascular stalks. I 
have often seen vegetations of this description adhering to the 
internal surface of the uterus by a broad or narrow stalk, and 
consisting merely of a crowd of small vesicles filled with a 
transparent fluid, and clustered together pretty much as a 
bunch of grapes. In some instances they have appeared to me 
to be completely independent of any placental connexion with 
the uterus. 

We sometimes find deposits of phosphate of lime in these 
vegetations. I saw a remarkable instance of this in a middle 
aged woman, whose uterus contained a pear shaped body which 
adhered to its mucous membrane by a slight pedicle. It was 
very vascular, and consisted of a kind of fleshy substance; near 
its centre was a hard concretion, apparently composed of phos- 
phate of lime. It appears that similar concretions have been 
found loose and unattached in the cavity of the uterus, and in 
some cases have been discharged during life. In a case relat- 
ed by Brugnatelli, there was found in the uterus a calculus 
weighing two ounces, the nucleus of which was a fragment of 
the tibia of a fowl. The same author found another uterine 
calculus composed of phosphate of lime and ammoniaco-mag- 
nesian phosphate. 

The mucous membrane of the uterus, instead of presenting 
any of the lesions of secretion or nutrition above described, 
may furnish its natural secretion in greater abundance than or- 
dinary. When the orifice of the organ is free, the fluid gene- 
rally flows out as fast as it is secreted ; sometimes, however, 
it first accumulates to a certain extent in the uterine cavity, 
and then comes away in gushes at intervals : in such cases its 
natural viscidity is diminished, and resembles serum more than 
mucus. But there is another, more uncommon case, namely, 
where the os uteri happens to be closed : a great quantity of 
fluid may then accumulate in the organ, which gradually in- 
creases in size as if it were in the gravid state. This is the af- 
fection that has been termed dropsy of the uterus, or hydrome- 



424 DISEASES OF THE 

tra. There is a remarkable case of it related by Dr. Thomp- 
son of London, in the Medico-chirurgical Transactions (vol. 
xiii.). The uterus was fully as large as if it contained a full 
grown foetus. On its being opened, there issued from it about 
eight quarts of a brownish fluid, slightly coagulable by heat ; 
the only alteration observed in the organ was the complete oblit- 
eration of the os uteri. 

Lastly, gases may accumulate in the cavity of the uterus, 
and distend it so as to produce the appearance of pregnancy. 
These gases generally result from the decomposition of the 
coagula. In some cases, however, there are no coagula, and 
it appears that they are then exhaled by the uterine mucous 
membrane, just as they often are by that of the alimentary 
canal. A few cases have been recorded of the escape of great 
quantities of gas by the vulva occurring in acute metritis. In 
such cases, the gaseous exhalation from the mucous membrane 
of the uterus is connected with irritation of that membrane : 
but there are also cases where this exhalation takes place with- 
out being preceded by any symptoms of inflammation, in con- 
sequence of some modification of the innervation: and it is in 
these cases that its secretion is the most abundant. 



CHAPTER II. 



Diseases of the Fallopian Tubes. 



These are few in number, but deserving of considerable at- 
tention, as they may have great influence on the developement 
of the product of conception. They consist of, 1. preternatural 
adhesions of the free extremity of the tubes ; 2. various changes 
in their capacity : or, 3. the presence of morbid productions in 
their parietes, or in their cavity. 



FEMALE GENITAL ORGANS. 425 

I have sometimes found the fringed extremity of one of the 
tubes adhering to the ovary of the same side ; in some instan- 
ces this was the sole lesion ; in others, it was merely a result of 
acute or chronic peritonitis. There are many facts of the 
same kind to be found described in authors. 

Dilatation of the fallopian tubes seldom occurs except in con- 
sequence of the accumulation of a morbid fluid. Obliteration 
of their cavity is not very uncommon, and may take place, 1. 
throughout its whole extent ; 2. towards its middle portion 
only ; 3. at is uterine extremity; 4. at is ovarian extremity. It 
may arise from various causes, such as the existence of a trans- 
verse septum in the tube, the stoppage of its uterine orifice by 
an accidental membrane lining the interior of the uterus, differ- 
ent alterations of texture of the fimbria, or an accidental or 
congenital agglutination of the parietes of the tube. 

Tuberculous or encephaloid matter, serous cysts, and calcu- 
lous concretions, may occur in the substance of the fallopian 
tubes; and their cavity may contain -an enormous accumula- 
of mucus or serum, which constitutes the disease described as 
dropsy of those tubes. In order that this accumulation should 
take place, it is necessary that both orifices of the tubes should 
be closed. In some cases of this disease, the cavity of the af- 
fected tube is wonderfully enlarged, so as to contain several 
pints of fluid. 

Instead of serum, we occasionally find pus in the fallopian 
tubes, which sometimes produces only a slight dilatation of their 
cavity, such as to admit the introduction of a quill, for instance; 
and in other cases is accumulated in such quantities as to con- 
vert the tube into a tumour of considerable size. This may 
occur without there being any disease in the corresponding 
ovary, or in the uterus ; but in general these three parts are af- 
fected together. 

The pus thus collected in the fallopian tubes may escape, 1. 
into the peritoneum ; 2. between the folds of the ligamenta lata; 
3. into the uterus ; 4. into some of the adjacent hollow organs, 
such as the bladder or rectum, particularly the latter. I saw 
lately at La Charitv a remarkable instance of the communica- 
tion of an abscess in one of the fallopian tubes with the rectum. 
Vol. II. 55 



426 DISEASES OF THE 

There is an accurate account of it to be seen in the Journal 
Hebdomadaire de Medecine, (Vol. i. p. 114.) 



CHAPTER III. 



Diseases of the Ovaries. 



Of the various alterations presented by these organs, some 
appear to affect chiefly their fibrous envelope, others their pa- 
renchyma, others, again, their vesicles, at least to have origina- 
ted there, and lastly, others, to be confined to no one particular 
part, but to involve them. all. 

The ovaries are not unfrequently affected with acute or 
chronic hypersemia, producing a redness of their parenchyma 
which is sometimes general, and sometimes confined princi- 
pally to the walls of the little cells that contain the ova, which 
then appear surrounded with a sort of red or brown areola. 
When the congestion of the ovary is at all considerable, it pro- 
duces an enlargement of the organ, which sometimes acquires 
an enormous size in a very short space of time. We then ob- 
serve, during life, a tumour situated above the pubis and at one 
side of the median line, to which it approaches as it increases 
in size, which it sometimes does very rapidly ; it may rise sev- 
eral finger's breadths above the margin of the pelvis, and, being 
more or less moveable, and of a rounded form, might easily be 
mistaken for the gravid uterus inclined a little to one side. 
Both ovaries may be thus affected at the same time. When 
examined after death, their tissue is found to be red, gorged 
with blood, and friable. It sometimes contains effused blood, 
and sometimes pus, either infiltrated or collected in abscesses. 

Suppuration of the ovaries is not always connected with a 
state of hyperemia so considerable as that now described. On 



FEMALE GENITAL ORGANS. ' 427 

the contrary, the ovary is often gradually transformed into a 
sac full of pus by an obscure chronic process, without any ap- 
preciable tumefaction, and sometimes even without pain. At 
the same time its fibrous capsule may become softened, and, 
eventually, perforated, and unless adhesions have been pre- 
viously formed between it and the neighbouring organs, the 
pus escapes into the peritoneum. On the other hand, if there 
happens to be adhesions between the ovary and the uterus, va- 
gina, bladder, or a portion of intestine, the parietes of the ad- 
hering part become ulcerated from without inwards, and the 
ovarian abscess opens into its cavity. I once found a com- 
munication of this nature between one of the ovaries and the 
bladder, in a young woman who died thirty-seven days after 
her confinement. 

Abscesses of the ovary sometimes acquire a very considera- 
ble size. In the North American and Medical Journal for 
1826, there is a case of a woman who had a tumour in the ab- 
domen, which, during life, was considered to result from en- 
cysted dropsy of the ovary. On dissection, it was ascertained 
that the tumour was in fact formed by one of the ovaries, 
which occupied a great part of the abdomen, and weighed 
seventeen pounds ; but the disease was not encysted dropsy, 
the entire organ being converted into a vast sac containing 
twenty pints of pus. 

The ovary is subject to numerous alterations of nutrition and 
secretion, either subsequently to irritation and active hypere- 
mia, or without any previous symptom of those affections. 

In the first place, its fibrous envelope is sometimes found so 
thickened as to constitute almost the whole of its bulk, and 
sometimes transformed into cartilaginous or osseous tissue. 

The parenchyma of the ovary likewise may be affected with 
hypertrophy producing an increase in its bulk and density. In 
other cases, on the contrary, it falls into a state of atrophy, and 
is then reduced to a small cellulo-fibrous mass, that is almost 
lost in the tissue of the ligamenta lata. Atrophy of the ova- 
ries is, however, a morbid condition only when it takes place 
prematurely ; for it is so common in old age, that it may then 



428 



DISEASES OF THE 



be considered as the natural state of the parts, which waste 
away, having no longer any functions to perform. 

We frequently find new formations in the substance of the 
ovaries. These are sometimes masses of encephaloid, and 
sometimes fibrous bodies. The latter are at first scarcely as 
large as a grain of millet, but afterwards gradually increases 
in size, so as at last to become much larger than the ovary it- 
self, of which there is then no vestige distinguishable. Some 
of these fibrous bodies are developed in the midst of the organ, 
others on its surface, and others merely adhere to its mem- 
branous envelope by a long and slender pedicle. They may 
be combined with amorphous masses of a cartilaginous or os- 
seous substance, just as in the uterus. 

The vesicles scattered through the parenchyma of the ovary 
are occasionally the part principally affected. Blood is some- 
times exhaled, or various colouring matters secreted, around 
them or in their interior.* In other cases they become dis- 
tended, enlarged, and at the last transformed into cysts, which 
present infinite varietes with respect to their size, their number, 
the anatomical composition of their parietes, and the qualities 
of the fluid they contain. This constitutes, properly speak- 
ing, the disease known by the name of encysted ovarian 
dropsy. 

The first degree of this disease seems to be the presence of 
one or more small serous cysts, with transparent parietes, full 
of a fluid resembling water. These cysts, without changing 
their nature, may increase in size, so as eventually to occupy 
half, three-fourths, or even the whole of the organ. In this 
state, the ovary often assumes the appearance of a single sim- 
ple or multilocular sac, filled with limpid serum. 

These, however, are not the only description of cysts found 
in the ovaries; there are others whose parietes are of a quite 
different texture, being formed sometimes of fibrous, cartila- 
ginous, or osseous tissue, and sometimes in a great measure of 
encephaloid. These parietes may become so very thick, and 



* Vide Vol. I. 349. Melanosis. 



FEMALE GENITAL ORGANS. 429 

the cavity of the sac so large, as to form a tumour occupying 
the whole of the abdomen, thrusting back the intestines, and 
reaching to the spleen, liver, and diaphragm. Externally, it is 
generally knobbed and uneven, and here and there presents 
considerable dilatations and contractions. In some parts of it 
we can discover a distinct fluctuation, while in others it is as 
hard and dense as a stone. In one case that came under my 
observation, the upper part of one of these tumours, which was 
situated in the left hypochondrium, formed a large fluctuating 
sac, separated by a hard and narrow neck from the rest of the 
tumour situated in the right iliac region. During the life of the 
patient, it was supposed that there were two distinct and in- 
dependent tumours in the abdomen, the nature of one of which 
was evident enough, while that of the other could not be de- 
termined, as it bore a much greater resemblance to a tumour 
of the spleen or of the left lobe of the liver, than to a portion 
of a tumour of the right ovary. 

The cysts in the interior of these tumours are not all of equal 
size. In almost every case I had an opportunity of examining, 
there was one much larger than any of the rest, in the anterior 
portion of the tumour. I am not sure whether this is uniformly 
the case, or merely an accidental circumstance. 

Whatever be the anatomical composition of the intermediate 
substance, the internal surface of the cysts is always lined with 
the same kind of membrane, which is smooth, thin, and more 
or less vascular; in short, possesses all the characters of a se- 
rous membrane. Yet, notwithstanding this identity of the 
lining membrane, each sac generally contains a different fluid, 
some of which are never found but in the ovaries. Pure se- 
rum, fluid or coagulated blood, pus, various fatty matters of 
different degrees of consistence, and a variety of colouring 
matters, some of them bearing a strong resemblance to choco- 
late, are not unfrequently contained in the same ovary; and 
there is often but a slight partition between a cell full of pus or 
serum, and another containing a suety matter, or, perhaps, tufts 
/ of hair. 

This last mentioned substance (hair) is sometimes found in 
encysted ovarian dropsy, but it is not in that affection that it 



430 DISEASES OP THE 

occurs most frequently. There is a sort of sebaceous matter, 
which is invariably present either in the interior of the ovary, 
or on its external surface, whenever this morbid developement 
of hairs takes place. There is no other morbid alteration which 
invariably accompanies them ; but, in many cases, teeth, frag- 
ments of bone, or rudiments of skin, are likewise found in these 
tumours. 

The hairs found in this singular situation are sometimes 
scattered through the fatty matter above mentioned, and some- 
times matted into a tuft. Their two extremities are generally 
alike, at least they were so in every case I had an opportunity 
of examining. Meckel, however, in his interesting memoir on 
the subject,* states that he has ascertained the fact of their 
being furnished with bulbs, like the natural hairs. In my 
opinion, when they are found implanted in the fatty matter, 
and do not adhere to any membrane, they have then no bulb; 
but when, on the contrary, they are fixed in a membrane more 
or less analogous to the skin, it is natural to suppose they have 
one. Their length varies from a few lines to upwards of a 
foot. The longest I ever saw myself were about six inches. 
In colour, they present every variety to be found in the hair of 
the head, to which they bear a greater resemblance than to 
that on any other part of the body; it is to be observed, how- 
ever, that they do not resemble the hair of the person in whom 
they are found, either in colour or in other particulars. This 
is remarkably exemplified in the case of the negress described 
in my Clinique Medicate, who had a large cartilaginous cyst 
in her mesentery filled with a sebaceous matter in which were 
imbedded a number of these hairs differing altogether from the 
black woolly hair on her head, inasmuch as they were smooth, 
fine, and of a light or reddish colour. Besides, it is by no means 
unusual to find hairs of different colours in the same tumour. 

The developement of teeth in the ovary is much more un- 
common than that of hairs. In almost every instance where 



* Memoirc sur les Poils el les Dents qui se developpent accidentellement dans le 
Corps, par Fr. Meckel, in the Journal Complementaire, Nos. 14 and 15. 



FEMALE GENITAL ORGANS. 431 

they have been observed, they were implanted in fragments of 
osseous or cartilaginous matter, which in some cases were 
merely amorphous masses, and in others appeared to be the 
remains or rudiments of maxillary bones, furnished with al- 
veoli. Meckel is of opinion that these accidental teeth are 
formed, iike the natural teeth, in capsules filled with a gelatin- 
ous fluid, and that their crowns are formed before their roots. 
He agrees, however, with Blumenbach, in opposition to Baillie, 
that the roots have been sometimes found perfectly developed. 

The osseous substance occasionally found in the ovaries 
mixed with hairs or teeth, appears to be in many cases merely 
the debris of an extra-uterine foetus, inasmuch as other pieces 
of the skeleton are also found ; but in other cases it is impossible 
to trace any resemblance between these accidental formations 
and the natural structure of the foetal skeleton. 

It is an interesting question to decide whether the rudiments 
of skin that are sometimes found in the ovarian cysts are con- 
nected with the abortive formation of a foetus. There is a case 
related by M. Reynaud in the Journal Hebdomadaire de Med- 
ecine, (torn. i. p. 475,) which seems to throw some light upon 
this subject. No doubt, in certain cases, these fatty masses 
found in the ovary, containing hairs, teeth, bone, and skin, pre- 
sent several of the elements of the body of a foetus, arranged in 
their natural order. But, this is not sufficient to prove that they 
are the rudiments of a foetus. For, similar masses have been 
found in girls who had not arrived at the period of puberty : they 
have also been found in other parts besides the ovary ; and, 
what affords a still stronger objection to the theory, they have 
been found likewise in the male subject. In some cases of 
gravel, published by Magendie, which I shall hereafter have oc- 
casion to cite, it appears that the kidneys actually secreted 
hairs; thus proving that they can be produced in other parts as 
well as in the skin, even in the male. Again, Ruysch states 
that he found in the stomach of an adult man an atheromatous 
tumour, which contained a shapeless bone, four molar teeth, 
and a tuft of hair. Meckel mentions two cases of a similar 
nature. 



432 DISEASES OF THE 

In the 13th volume of the Medico-chirurgical Transactions, 
there is an account given by Dr. Gordon of a tumour which 
was situated in the thorax of a woman, and the contents of 
which bore a much greater resemblance to the debris of a 
fetus than any of those above mentioned. If it were really 
such, it can only be accounted for by the theory of monstrosity 
by inclusion, so ably discussed by M. Ollivier in a memoir pub- 
lished in the Archives de Medecine. 



CHAPTER IV. 



Diseases of the Breasts. 

These, though properly belonging to surgery, demand our 
attention here, in consequence of the light which many of them 
are capable of throwing on the nature of certain alterations of 
the internal organs, particularly scirrhus. The diseases of 
those organs may, I conceive, all be reduced to certain mod- 
ifications in the nutrition of the various anatomical elements of 
the mammas, or to morbid secretions developed in the cellular 
tissue which enters into their structure or invests their surface. 
These affections have almost all been confounded under the de- 
nomination of scirrhus or cancer of the breast. 

I shall commence with those alterations that depend on a 
derangement of the nutrition of the part. The most simple of 
these is induration of the mammary gland. In this state, the 
tissue of the gland remains perfectly distinguishable, being 
merely altered in its density and hardness. The component 
cellular tissue is likewise unchanged. The induration may be 
either general or partial ; in the latter case, the indurated 
points may project more than the rest of the gland, and thus 
give it a knobbed appearance. 



FEMALE GENITAL ORGANS 433 

This affection is occasionally confined to the walls of the 
lactiferous ducts, which are at the same time hypertrophied, 
and considerably dilated. This seems to occur mostly in el- 
derly women. It is a singular circumstance that, in all the 
cases of it I have seen, the nipple, so far from sharing in the 
hypertrophy, had disappeared, and the ducts were obliterated 
before they reached it. 

The. mammary gland, while becoming indurated, may at the 
same time diminish in size. Its natural anatomical elements 
then still remain, but its tissue becomes much more dense, com- 
pact, and dry, the fat completely disappearing, and the cel- 
lular tissue being scarcely perceptible. The dilatation and 
thickening of the lactiferous ducts described in the preceding 
paragraph, may be present in this case also. 

Another kind of induration of the mammary gland is that in 
which the cellular tissue becomes greatly thickened, while the 
proper tissue of the gland is more or less wasted. In this case, 
the gland, when cut into, presents septa of a dead or silvery 
white colour, and fibro-cellular or even tendinous structure, 
which divide it into lobes, lobules, and grains, so as to make it 
resemble the tissue of the pancreas or of a salivary gland. As 
the disease advances, this granulated appearance vanishes, all 
trace of glandular tissue is lost, and we find nothing but masses 
of a fibro-cellular substance, or else a single, hard, homogene- 
ous mass, without any apparent organization, which appears to 
be cellular tissue at its maximum of condensation, and it is 
termed scirrhus. These various alterations may affect the 
whole gland or only a part of it. 

The diseased portion of the gland may either be continuous 
with the sound parts, or completely separated from them by 
means of a fibro-cellular envelope. The internal surface of the 
envelope often sends forth processes, of the same nature with 
itself, into the contained morbid mass ; in other cases, the only 
means of a connexion between them are a few soft cellular fila- 
ments, so that the tumour can easily be extracted from its in- 
vesting membrane, like the kernel of a nut from its shell. When 
the whole gland is indurated, it is sometimes in like manner 
surrounded by an envelope of condensed and hardened cellular 

Vol. II. 56 



434 DISEASES OF THE 

membrane, particularly when it is at the same time diminished 
in bulk. In other cases, however, instead of being thus isola- 
ted, it contracts adhesions much closer than ordinary, either 
with the parts beneath it, or with the skin. In such cases, the 
alteration is not confined to the cellular tissue of the gland itself, 
but extends to that of the neighbouring parts, which then be- 
comes in like manner transformed into hard masses of a fibrous, 
cartilaginous, or scirrhous appearance. This alteration may 
extend to the cellular tissue of the axilla, and even to the sur- 
face of the bones. The periosteum is then often affected, and 
the bone itself becomes diseased in consequence, and is ulti- 
mately destroyed by necrosis. While this change is going on 
in the deep seated parts, the superficial do not escape, and 
sooner or later the skin becomes involved in the affection of 
its subjacent cellular tissue. This, however, seldom happens 
until the cellular tissue subjacent to it has become so diseased 
that it can no longer be moved over the tumour, but feels as if 
incorporated with it. About this period, there often appear 
on the surface of the tumour numbers of hard round pimples, 
which evidently result from a circumscribed induration of so 
many portions of the cutis vera, which is probably of the same 
character, and produced by the same cause, as that of the sub- 
jacent tissues ; and it is very remarkable, that the skin of the 
whole body is sometimes in a very short space of t : .me covered 
with similar hard nodules, which are also found in many of the 
internal organs. In several instances, the developement of 
these nodules can be distinctly traced to the period of the re- 
moval of the tumour from the breast, thus establishing the fact 
of a genera] or constitutional cause producing similar effects 
all over the body. As soon as the skin immediately over the 
tumour has contracted adhesions with it, so as to be no longer 
moveable, it becomes irritated, red, softened, and ulcerated in 
one or more points, which subsequently unite in one large ul- 
cer. In some cases this ulcer remains a long time stationary ; 
in others, it extends rapidly, either superficially, or both in sur- 
face and depth. For an account of the various appearances 
assumed by these ulcers, and of the effects they produce, I 
must refer the reader to works on surgery, where he will find 



FEMALE GENITAL ORGANS. 435 

them fully detailed. When we consider that these ulcers are 
formed over parts whose organization is already seriously al- 
tered, and has a constant tendency to become still more so, it 
will be easy to conceive why they cannot possibly have any 
disposition to heal ; for, before that could take place, the deep 
seated disease should first be healed. Accordingly, if by any 
chance some of these ulcers do cicatrize, they either open 
again, or fresh ones break out beside them. It is true that, in 
a few instances, a durable cicatrization has been effected, but 
then the tumours beneath underwent. a spontaneous modifica- 
tion, having shrunk and contracted so as to form only a small 
hard mass, isolated from the surrounding parts by a cellulo- 
fibrous envelope. It appears that one of the best results of 
the system of compression so frequently employed by M. Re- 
camier in his treatment of cancerous diseases, is the production 
of this modification and isolation of the tumour, in which he has 
been sometimes so successful as to be able to extract it with his 
fingers after making an incision into the skin, above it. 

While the skin thus softens and ulcerates, or even before that 
period, the scirrhous mass beneath undergoes a remarkable 
change. It is traversed by a number of blood-vessels, which 
ramify chiefly on the septa that divide its interior into lobules ; 
it next gradually loses its original hardness, and becomes infil- 
trated with serous, gelatinous, bloody, or purulent fluids, and at 
last becomes a mass of half solid half fluid matter, in which 
may be observed every variety of accidental production from 
pus to tubercle, encephaloid, or melanosis, all blended to- 
gether. 

In the various forms of alteration hitherto described, the 
blood-vessels do not make their appearance for a considerable 
time after the commencement of the scirrhous tumour. There 
is, however, another morbid state of the breast, in which they 
are the principal part of the disease, being considerably aug- 
mented in size, and developed in amazing numbers ; the cellu- 
lar tissue likewise vegetates at the same time, but seems to do 
so merely in order to support the immense vascular net-work 
which of itself constitutes the greater part of the tumour, and, 
when cut into, bears some resemblance to the interior of the 



438 DISEASES OV THE 

spleen. The skin over the tumour thus formed ulcerates, and co- 
pious haemorrhages constantly issue from the bottom of the 
ulcer. I lately saw a remarkable case of this kind in a man of 
about sixty years of age : the tumour, which was as large as a 
child's head, occupied the right side of the thorax ; it was soft, 
painful, and bled profusely on the slightest touch. The man 
told me he had been bitten by a horse in the right nipple some 
years previously, and that soon after a red spot appeared on the 
part where he had received the bite, which gradually became 
prominent, and was at last transformed into this enormous tu- 
mour. This man was accompanied by a son, who had a small 
reddish excrescence, possessing all the characters of the erectile 
tissue, on his cheek, where he had received a slight blow eight- 
een months before. 

Lastly, there are some tumours of the breast which originate 
in its lymphatics. This morbid alteration is characterized by 
some of the lymphatic ganglions which are scattered through 
the substance of the gland becoming enlarged and indurated ; 
at the same time they present a red colour, or in some instan- 
ces a grey transparent appearance. At first, the parts around 
appear perfectly healthy ; but subsequently these ganglions in- 
crease in size and number, the surrounding cellular tissue par- 
ticipates in the alteration, and at last the disease assumes the 
same characters as those already described in the preceding 
paragraphs. 

The several alterations of the breasts we have hitherto con- 
sidered originated in the lesions of nutrition, and were only 
complicated with lesions of secretion towards their termina- 
tion; but we now come to a class of these diseases in which 
the lesions of secretion constitute the primary affection. These 
lesions are almost exclusively confined to the cellular tissue. 

Inflammation of the mamma?, whether acute or chronic, is 
often followed by the formation of pus; but the origin, nature, 
and symptoms of mammary abscesses have been so often and 
so fully described that I need not dwell upon them here. 
Another morbid production not unfrequently developed in the 
cellular tissue of the mammae are cysts, which may contain 



FEMALE GENITAL ORGANS. 437 

either serum, gelatinous, colloid, or encephaloid matter, tuber- 
culous matter, or hydatids. 

I have now enumerated the various organic alterations that 
occur in the breasts. We must bear in mind, however, that 
these are all local effects, produced by a general cause, and con- 
sequently that cancer of the breast is not to be regarded as a 
local lesion, but merely as a symptom of a general diathesis, 
which preceded its formation in that part, and may produce it 
in many others : so that, when we remove the local lesion, we 
in fact only destroy a symptom of the disease, not the disease 
itself; on the contrary, we thereby render it in many cases 
more dangerous and more speedily fatal. How often do we 
sec the diathesis which had previously remained latent, quickly 
manifest itself after the removal of the diseased part, and cause 
a developement of cancerous tumours in other parts of the 
body. Were it necessary, I might adduce another powerful 
argument in support of cancer being a constitutional, not a 
local disease, in the peculiar dingy tinge of countenance which 
invariably accompanies it, and frequently affords the experi- 
enced practitioner a more unerring diagnostic mark of the true 
nature of the disease, than could be obtained from an exam- 
ination of the physical characters of the local affection itself. 



CHAPTER V. 



Diseases of the Foetus and its Appendages. 



The amnion sometimes exhales a much greater quantity of 
serum than ordinary, and thus produces a particular kind of 
dropsy, which is described in every work on midwifery. Se- 
rum may also accumulate in the delicate cellular tissue that 
unites the amnion and chorion ; blood has likewise been effus- 



438 DISEASES OF THE 

ed between these membranes. The amnion is also liable to 
inflammation, one of the effects of which is the formation of 
adhesions between the opposite surfaces of the membrane, 
which, according to M. St. Hilaire, is the cause of certain mal- 
formations of the fetus. 

The placenta, besides occasionally contracting preternatural 
adhesions with the uterus, being situated on the cervix uteri, 
and deviating from the natural form, is subject to most of the 
lesions of nutrition and secretion observed in other organs. 
Thus it is sometimes found in a state of hypertrophy, and ac- 
cording to M, Desormeaux,* one of the varieties of the mola 
cornosa of authors consists in this affection of the placenta. 
In other cases, it is remarkably small, and withered, in short, 
is reduced to a perfect state of atrophy, the consequence of 
which is an arrest of the developement, and sometimes even the 
death, of the fetus. .-Pus and other morbid secretions, such as 
osseous and calcareous concretions, have occasionally been ob- 
served in the placenta. 

Amongst the morbid productions that are sometimes devel- 
oped on the uterine surface of the placenta, and apparently in 
the place of a fetus, must be reckoned the mass of vesicles al- 
ready alluded to as occurring in clusters like grapes. Some 
authors have imagined that these can only arise from the dila- 
tation of the superficial vessels of the placenta; and the natural 
disposition of those vessels affords some support to the opinion. 
In the work already cited, there is an accurate description of 
them, to which I refer the reader. 

The diseases of the embryo and fetus are numerous, consist- 
ing of most of those that have been observed after birth, to- 
gether with numbers that occur exclusively during the period 
of intra-uterine existence, namely, the various congenital mal- 
formations. The latter have been already fully described. 
Many of the former, also, have been mentioned in various 
parts of this work; so that I shall merely give a general sketch 
of them here. 



* Dictionnaire de MHecine. par MM. Adelon, Andral, Beclard, &c., art. (Euf. 



FEMALE GENITAL ORGANS. 439 

The alimentary canal is often found more or less injected in 
stillborn infants; but the causes that may produce this during 
delivery are so numerous, that it is not of itself sufficient to 
prove that there has been a process of irritation in the intes- 
tines before birth. In other cases, it is perceptibly softened, 
and its internal surface remarkably pale; which, in my opinion, 
is a much more certain indication of disease than the former. 
In an infant that came into the world in an emaciated state, 
and died in six days after birth, M. Billard found in the duod- 
enum a vegetation of the mucous membrane, which had evi- 
dently grown there before birth. In another infant that was 
also but six days old, he discovered a scirrhous induration of 
the submucous cellular tissue of the intestine, which in like 
manner must have taken place before birth. In children that 
died on the second or third day after birth, he found Peyer's 
glands red and tumid, some of the isolated follicles in an incip- 
ient state of ulceration, and circumscribed red patches on the 
intestinal mucous membrane. 

The circulatory apparatus also of the foetus occasionally pre- 
sents some remarkable lesions. It is a fact that one would 
never imagine a priori, that irritation of the pericardium, ter- 
minating in the formation of false membranes or purulent ef- 
fusion into its cavity, is a common enough disease in the foetus, 
even more so perhaps than in the adult. In one of the cases 
of this affection observed by M. Billard, the two folds of the 
pericardium were united by very strong adhesions, so that the 
disease must have occured long before birth. The same author 
once found in an infant only two days old considerable dilata- 
tion of the right cavities of the heart, together with extreme 
attenuation of their parietes; and in another of the same age, 
an aneurism of the ductus arteriosus. Lastly, the blood itself 
of the foetus is sometimes altered in its physical properties, and 
becomes transformed into a fluid like chocolate. 

The respiratory apparatus is subject to some very serious 
lesions in the foetus. The lungs have often been found hepa- 
tized in infants that were stillborn, or that died in a few hours 
after birth: I have seen two cases of it myself. In another 
case, I met with numerous abscesses in one lung. Tubercles, 



440 DISEASES OF THE 

as I have already mentioned, are very rare in the fetal lung. 
In the pleura, there have been found false membranes, and ef- 
fusions of serum, blood, or pus. 

The following apparatuses of secretion are occasionally 
found diseased in the fetus. 

1. The cellular tissue. The alteration of this tissue has al- 
ready been described. (Oedema sive induratio telce cellulosm 
neonatorum. Anglice, Skinbound.) 

2. The serous membranes. I have just described the altera- 
tions occasionally observed in the pericardium and pleura of 
the fetus: the peritoneum is also subject to the same affections. 
I found all the intestines soldered together by firm cellular ad- 
hesions in an infant two days old. 

3. The liver. Hyperemia of this organ, with or without 
effusion of blood, is a common affection in the fetus. Tuber- 
cles have also occasionally been found in it. 

4. The kidneys. These have been often found transformed 
into large sacs containing a serous or purulent fluid ; an altera- 
tion which, in the fetus, is generally connected with a perfect 
or imperfect obliteration of the uterus or urethra. Hoffman 
relates a case of a calculous concretion being found in the blad- 
der of a female infant three weeks old, whose mother presented 
all the symptoms of a calculus in the kidney. 

The principal diseases of the cerebro-spinal apparatus in the 
fetus that have been hitherto described are, various degrees of 
active and passive hyperemia, effusions of blood in or around 
the nervous centres, softening of their substance, sometimes at- 
tended with a remarkable smell of sulphuretted hydrogen, col- 
lections of pus in the brain, an accumulation of serum in the 
ventricles, and various malformations depending mostly on an 
arrest of developement. 

The integuments of the fetus may present several morbid 
conditions resembling those observed in the same parts after 
birth ; such as small-pox, measles, pemphigus, syphilitic ulcers, 
&c. Dislocations and fractures, too, have been occasionally 
observed in the fetus, but their cause is still unknown. Lastly, 
the thymus and the supra-renal capsules have been sometimes 
found in a state of suppuration. This long list of diseases to 



FEMALE GENITAL ORGANS 441 

which the fetus is subject affords abundant proof that the dif- 
ferent alterations to which our organs are liable, may arise 
spontaneously, or at least independently of any external in- 
fluence. 

The fetus is occasionally developed elsewhere than in the 
cavity of the uferus ; and the pregnancy is then said to be ex- 
tra-uterine. Of this there are four kinds, according as it takes 
place in the cavity of the peritoneum, in the ovary, in one of 
the fallopian tubes, or in the substance of the walls of the 
uterus. The three first have long been known ; the fourth has 
been lately described in a memoir by M. Breschet, in the first 
volume of the Repertoire d 'Anatomie ; and we have at present 
nine well authenticated cases of it on record. 

When the embryo is developed in the peritoneum, it is al- 
ways contained in a cyst. When in the ovary, that organ is 
transformed into a vast sac. When in the fallopian tube, the 
portion which contains it is considerably dilated, while the rest 
of the tube retains its usual form and dimensions. Lastly, 
when the pregnancy occurs in the substance of the walls of the 
uterus, the embryo is contained in a sac situated at either angle, 
near the insertion of the corresponding fallopian tube, and 
formed of the proper tissue of the organ more or less modified. 
Of the nine cases of this description which have been observed, 
six occurred at the left side and three only at the right. The 
sac in which the fetus is contained has no communication 
whatever either with the cavity of the uterus or with the adja- 
cent fallopian tube, the uterine orifice of which is invariably ob- 
literated. The latter circumstance throws considerable light 
on the way in which this variety of extra-uterine conception 
takes place. 

The embryos that are developed either in the substance of 
the walls of the uterus, or in the fallopian tube, never come to 
their full time. In a few months after conception the investing 
sac bursts, and they fall into the cavity of the peritoneum, 
where they almost in every instance produce a fatal inflam- 
mation. 

In the two other kinds of extra-uterine pregnancy, the fetus 
may come to its full time, and the mother then begins to ex- 
Vol. II. 57 



442 DISEASES OF THE, ETC. 

perience all the symptoms that usually precede delivery. In 
some cases, death occurs, during the progress of these symp- 
toms : in others, they disappear, the fcetus dies, and may con- 
tinue for an indefinite period in the abdomen of the mother, 
without producing any unpleasant effect; lastly, mothers, after 
a longer or shorter period, fragments of the foetus are expelled 
by the rectum, or by a fistulous aperture formed spontaneously 
in some part of the abdominal parietes : death sometimes oc- 
curs during this process of expulsion, while, in other instances, 
a perfect recovery ensues. 

The fcetus undergoes very remarkable changes during this 
protracted residence in the ovary or peritoneum. In some 
cases the skeleton alone continues to be developed, and, on 
opening the body of the mother, is found as completely formed 
as in a fully formed infant ; the bones, however, are remark- 
ably small, and are crowded together without preserving their 
natural relative situations. In other cases we find only some 
fragments of the skeleton, together with teeth, pieces of skin, 
and hairs, all impacted in a fatty substance ; and, in others 
again, we find a cyst containing a perfect and fully formed 
fcetus. A very remarkable case of this description is recorded 
• in an American. Journal for May, 1828. The subject of it 
carried in her abdomen for forty years a full grown, well form- 
ed foetus, which during that long period had not undergone any 
considerable alteration except the ossification of a great portion 
of the integuments. The walls of the cyst in which it was 
contained were likewise ossified. There was no trace of an 
umbilical cord or placenta to be discovered. 

In all cases of extra-uterine pregnancy, the uterus under- 
goes some of the changes which usually take place in it when 
it contains the embryo : thus, it increases in size, its tissue as- 
sumes a muscular appearance, and a decidua is formed on its 
internal surface. The breasts, too, become humid, and milk is 
secreted as usual. 



APPARATUS OF INNERVATION. 443 



APPARATUS OF INNERVATION. 



If the variety of the functional derangements of an organ 
bore any constant proportion to that of its derangements of 
texture, no part should present a greater variety of lesions than 
the nervous centres and the nerves: such, however, is not the 
fact; these lesions are few in number, and frequently bear no 
proportion to the nature or intensity of the symptoms; nay, it 
sometimes happens that we cannot discover any lesion what- 
ever in the nervous system, although its functions have been 
seriously deranged during life. It is, however, highly probable 
that some organic lesions do exist in such cases, though they 
escape our notice ; and as there are few functional disorders of 
the brain or other parts of the nervous system which may not 
thus occur without any appreciable lesion, it follows that, when 
we do find an alteration of structure in those parts, we ought 
to be cautious how we attribute the functional derangement to 
it, inasmuch as such alteration is often purely accidental, sec- 
ondary, or consecutive, and the derangement of function de- 
pends on some other lesion which altogether escapes our 
notice. What strengthens this view of the subject is, that we 
find that a lesion which produces certain symptoms in one case, 
does not produce any symptom at all in another; and that the 
same lesion may be accompanied by the most dissimilar symp- 
toms, and the most dissimilar lesions by the same symptoms. 

Accordingly, notwithstanding the ingenious researches which 
have lately been made in this department of pathology, we 
must for the present observe considerable caution and reserve 
in our attempts to explain the derangements of the functions 



444 APPARATUS OP INNERVATION. 

of the nervous system observed during life, by the nature of 
the organic lesion found after death. Neither can we come 
to any morp positive conclusion from the situation of the lesion; 
for, morbid anatomy has but rarely confirmed the conclusions 
relative to the functions of the various parts of the nervous 
system drawn from experimental physiology, or comparative 
anatomy; while, on the contrary, it has often invalidated 
them. 



DISEASES OF THE BRAIN AND SPINAL CORD. 445 



SECTION I. 



DISEASES OF THE BRAIN AND SPINAL CORD. 



CHAPTER I. 



Lesions of Circulation. 



ARTICLE I. 



HYPEREMIA. 



There are two degrees of hyperemia of the nerves and 
nervous centres: in the first, the capillaries are simply dis- 
tended; in the second, the blood is effused into the nervous 
substance. 

§ I. Hyperemia without Effusion of Blood. 

It is not always easy to detect the existence of this kind of 
hyperemia, owing to the variations in the natural degree of 
vascularity according to the part examined, the age of the sub- 



446 DISEASES OF THE BRAIN 

ject, the nature of the disease, and the kind of death. To these, 
therefore, we must first direct our attention.* 

If we examine the two component substances of the nervous 
centres, we find them presenting different shades of colour in 
different parts, according to the number and size of the vessels 
of those parts. For instance, the grey substance of the cere- 
bral hemispheres generally appears more strongly injected in 
the depressions than in the convolutions, and in both it is in 
general much less vascular than the white substance, or at 
least its vessels are much less apparent. 

In young people and adults the colour of the cortical sub- 
stance of the cerebral hemispheres resembles that of weak 
coffee mixed with a great deal of milk. Its surface is found 
sprinkled over with red dots arising from the rupture of the 
meningo-cephalic vessels, and its interior is traversed by some 
small vessels. In elderly people, this substance becomes paler 
and more of an ashy colour; and in very advanced age, it ac- 
quires a slight yellowish tint, which, however, sometimes ap- 
pears prematurely at a much earlier period. It is composed of 
three distinct layers, which may be easily discovered by making 
a horizontal section through one of the convolutions. The first 
is of a whitish grey; the second, which is very thin, of a dirty 
white; and the third, which is the thickest, of a leaden grey; 
it is in this layer that the vessels are generally most apparent. 
M. Cazauvieilh states that the middle layer is not equally visi- 
ble in all brains, nor in all the convolutions of the same brain : 
and it is hard to say what effect its greater or less develope- 
ment may have as well in the healthy, as in the diseased state. 

The white substance of the cerebral hemispheres is of a 
milk white colour in young people and adults ; after the fiftieth 
year, it gradually becomes of a deader white ; and, in old age, 
it assumes a slight yellowish tint, like the cortical substance. It 
contains more vessels in children than in adults, and in adults 
than in old people ; whence it follows, that when we find the 



♦Cazauvieilh, Recherches anatomico-physiologiques sur I'encephale, considers 
chez Vadolescent, I'adulte, el le viellard. 



AND SPINAL CORD. 



brain of an old person as vascular as that of a child, it is to be 
considered in a morbid state. 

In the ihalami optici, the external layer ought to be of a 
purer white than that of the white substance of the hem- 
ispheres ; and some small vessels may appear on its surface 
without constituting a morbid state. The internal grey sub- 
stance is pale, and in some points rose-coloured, in young peo- 
ple ; later in life, it becomes of a deeper grey, and in old per- 
sons assumes a slight yellowish tinge. 

In the corpora striata the external grey substance is naturally 
of a deeper colour than the grey substance of the thalami op- 
tici. It contains some small rose-coloured patches, and a few 
red points, and is traversed by vessels of considerable size. 
The white substance is less vascular than the grey : they both 
acquire a yellowish tint in old age. 

The corpus callosum is of a somewhat less pure white than 
the medullary substance of the hemispheres, and generally con- 
tains very little blood. 

The fornix has scarcely any vascularity whatever, and ac- 
cordingly ought to be of a uniform white colour. The same is 
the case with the corpora mamillaria, and with the white en- 
velope of the cornua Ammonis. 

The interior of the cerebellum is of a reddish grey colour, 
which perhaps depends on the dependent position in which it 
generally lies. Its white substance is generally traversed by 
fewer vessels than that of the cerebral hemispheres. How- 
ever, it is common enough to see large vessels in the neighbour- 
hood of the corpus rhomboideum. 

The tuber annulare is generally dotted with red points, 
which are less numerous and smaller than those found in the 
hemispheres. The white substance of which it consists is mix- 
ed with another substance, of a pale, dark, or yellowish grey, 
according to the age of the subject. 

The tubercula quadrigemina are of a less pure white than the 
other parts of the brain composed externally of the medullary 
substance ; the grey substance in their interior presents a red- 
dish tint. 



448 DISEASES OF THE BUAIN 

The pituitary gland is usually reddish, especially in its ante- 
rior portion. I have sometimes found effused in it a matter re- 
sembling the lees of wine, in persons who had never presented 
any symptoms of a cerebral affection ; but I do not know 
whether it is a morbid condition of the part or not. 

The white substance of the spinal cord is usually of a beau- 
tiful milk white colour, and contains but few red points. The 
grey central substance is often slightly reddish. 

In persons that die of acute disease, the different parts of the 
cerebro-spinal axis are more injected than in those who die of 
chronic affections. The injection is also much greater where 
the patient has died in a state of asphyxia. 

Lastly, after death, there are two causes which may produce 
a considerable redness in the mass of the encephalon. One of 
these is the prolonged exposure of the brain to the air, after 
stripping it of its membranes, or cutting some slices from its 
substance ; the other is the dependent position in which the 
cranium may happen to lie, which produces the hypostatic hy- 
persemia already frequently alluded to. 

We now come to the proper subject of this article, namely, 
the hypersemia of the nervous substance produced by disease. 
This substance then presents various forms and shades of col- 
our. 

The most common is the red colour, of which there are two 
kinds, the dotted and the uniform. 

The dotted redness is particularly remarkable in the medul- 
lary substance, where it is merely a morbidly increased degree 
of the natural dotting of the part. The appearance of the 
brain in this species of redness has been compared by M. Lal- 
lemand to that of a white surface sprinkled over with red sand, 
and accordingly he has given it the name of "injection sabUe." 
It may be general or partial,' and frequently appears strongly 
marked around effusions of blood. When very intense, it gives 
the part a rose-coloured tinge, and then approaches closely to 
the uniform redness. After all, this kind of redness can only 
be considered as decidedly the result of active hyperaemia of 
the brain, when it is very well marked ; and even then we 



AND SPINAL CORD. 449 

must always allow for the kind of death the person has suf- 
fered. 

The uniform redness is much less frequently the anatomical 
sign of active hypersemia of the brain. It is never general, and 
may exist in either of the two substances. It is seldom ob- 
served in the white, and when it does occur there, it is mostly 
in the neighbourhood of an effusion of blood, though it may 
also exist in it without there having been any haemorrhage. 
The white substance then presents sometimes a light rose-col- 
oured, and sometimes a deep red tint, which occasionally bears 
an exact resemblance to the colour of mahogany. It may also 
appear in the grey substance, which then assumes a reddish or 
scarlet tint. This redness in its various degrees has been seen, 
1. in the grey substance of the convolutions, either involving 
them all, or confined to some particular ones ; 2. in the grey 
substance scattered through the various parts of the cerebro- 
spinal mass. 

This uniform redness of the cerebral substance assumes so 
many shades that it has been described as purple, violet col- 
oured, of the colour of lees of wine, of chocolate, or of mahog- 
any. In other cases it becomes brown or greenish, and, lastly, 
in others, certain parts of the brain, especially around appo- 
plectic effusions, have been found tinged with various shades 
of yellow. But, as we often observe this yellow colouring pass- 
ing insensibly into various shades of red, we must conclude 
that the former results from sanguineous congestion as well as 
the latter. In fact, all that is requisite to form any of the 
shades above described, is a change in the proportion of the 
colouring matter of the blood. 

We have already seen, in other tissues, the red tinge pro- 
duced by acute irritation passing, from various causes, into a 
brown or slate coloured tint : the same occurs sometimes in the 
brain also. M. Billard observed this slate coloured tint in the 
cortical substance of the cerebral hemispheres in two individu- 
als who had presented all the sig.is of chronic irritation of the 
brain. In a third, in whom he also observed it, death occur- 
red in three days after a fall upon the head. It was a child of 
twenty-two months old, whose leg was broken by the wheel of 
Vol. II. 58 



450 DISEASES OF THE BRAIN 

a coach : there was at first violent fever and great restlessness, 
and then profound coma terminating in death. On dissection, 
the cerebral hemispheres were found in a remarkable state of 
turgescence, and their cortical substance was of a slate colour- 
ed tint, quite different from its natural grey colour. Before 
the accident, the child had never shown the least symptom of 
functional derangement of the brain.* 

This slate coloured tint, instead of spreading uniformly over 
the whole of the cortical substance of the hemispheres, may be 
confined to a few points in it. M. Billard found, in front of 
an old apploplectic cicatrice situated in the corpus striatum, a 
slate coloured spot, which commenced at the anterior portion 
of the centrum ovale, and extended to the surface of the ante- 
rior lobe, its depth of tint increasing all the while. The cor- 
responding portion of the cortical substance was somewhat red, 
and depressed for an extent of about half an inch.f 

Hyperemia of the nervous centres without effusion of blood 
appears at all ages, but is particularly frequent at birth and in 
old age. At the first mentioned period, it results from the 
great quantity of blood received by the brain in the number- 
less vessels with which it is then furnished. In old age, the 
brain receives much less blood than in infancy, but then it is 
often sent there in a violent or irregular manner, and by jerks 
as it were, in consequence of the hypertrophy of the heart so 
frequent at that age. Besides, the arteries have generally 
lost some of their elasticity, so that the distribution of the blood 
is unequal, and performed with difficulty ; and the flaccidity of 
the veins retards its return. 

Hyperaemia of the brain, at whatever period of life it ap- 
pears, may occur in three different ways : 1. it may acquire its 
highest degree of intensity quite suddenly, and produce symp- 
toms of appoplexy terminating rapidly in death ; 2. there may 
be several sudden attacks of it, in the intervals of which the 
health is unaltered, until at last it returns with more violence, 



* Archives de Medecine, vol. ix. p. 492. 
t Ibidem. 



AND SPINAL CORD. 451 

and death ensues ; 3. it gradually attains to a certain degree of 
intensity, and then presents symptoms of encephalitis instead 
of those of appoplexy.* 

Hypersemia of the nervous centres often produces the same 
symptoms as are ordinarily referred to haemorrhage or ramol- 
lisement. In some cases it accompanies the latter ; and, in 
others, appears to be the prelude to, and accompaniment of, 
the former. Lastly, it often accompanies an increase of densi- 
ty of the substance of the brain. 

In most cases of hyperaemia of the brain, the investing mem- 
branes, especially the pia mater, are also congested. In some 
instances, there is an effusion of a turbid or a limpid serum into 
the ventricles, or into the subarachnoid cellular tissue of the 
convexity of the hemispheres. In others, on the contrary, the 
different external or internal surfaces of the encephalic mass 
are deprived of their natural humidity, and the arachnoid in par- 
ticular is remarkably dry. 



§ II. Hyperemia with Effusion of Blood. 



There are few parts of the nervous centres in which effusions 
of blood have not been observed. They may be divided into 
three classes, according as they occur on the external surface 
of the nervous centres, in their cavities, or in their substance. 

Those of the first class are of two kinds: in the one, a small 
quantity of blood is effused beneath the pia matter, in one or 
two of the anfractuosities; in the other, the blood is effused in 
a uniform layer extending sometimes over the whole of a cer- 
ebral hemisphere, and sometimes around the spinal cord. This 
happens frequently in new-born infants, but is unusual at other 

periods of life. 

Those of the second class are scarcely more common than 
the preceding. We certainly often find blood effused in the 



* Bouiliaud, Traite sur I'encephalite. 



452 DISEASES OF THE BRAIN 

ventricles in cases of apoplexy, but such effusion is almost al- 
ways the result of the rupture of their parietes, whereby a 
communication was established between them and the acci- 
dental cavity formed by the blood in the substance of the brain. 

In fact, it is there that the haemorrhage most frequently oc- 
curs: in 392 cases of cerebral haemorrhage I have found de- 
scribed in authors, the seat of it was in some part of the sub- 
stance of the brain in so many as 386, in 202 of which it occur- 
red in the part of the cerebral hemispheres on a level with the 
corpora striata and thalami optici, as well as in those parts 
themselves. 

The size of the cavities formed by the effused blood is very 
variable, some being scarcely as large as a pea, and others oc- 
cupying almost a whole hemisphere. When a considerable 
effusion takes place in one of the hemispheres, it generally rup- 
tures the walls of the lateral ventricles ; the septum lucidum, 
also, is often torn, the fornix destroyed, and their place occupied 
by large coagula of blood. In other cases, the effusion makes 
its way to the exterior of the brain, and the blood then spreads 
over the cavity of the arachnoid. 

The number of these cavities is equally variable, there being 
sometimes but one, sometimes two, and sometimes a great 
many. When there are many in the same brain, they are sel- 
dom found all in the same state, but generally appear to have 
been formed at different periods; and if we then inquire into 
the history of the case, we find that the person has had several 
attacks of apoplexy before the last fatal one. Effusion fre- 
quently takes place in some part of the cerebral hemispheres 
without occurring elsewhere ; whereas it seldom occurs in the 
cerebellum without appearing in the cerebrum also. 

It appears from the researches of M. Rochoux and others, 
that cerebral haemorrhage seldom occurs till after fifty, and is 
most common between the ages of sixty and seventy. How- 
ever, cases of it have been observed at all ages. M. Billard* 
mentions one where it occurred three days after birth ; and 



: Traiti des Maladies det Enfant, p. 600. 



AND SPINAL CORD. 453 

M. Serres, another, in a child three months old.f M. Guersent 
also saw a case of its occurrence at a very early age.J I saw 
an instance of it myself in a boy of twelve. 

The effused blood varies greatly in appearance according to 
the time elapsed after its effusion. At first it resembles thin 
currant jelly, and some of it still remains fluid. Somewhat 
later, twelve or fifteen days after the attack, for instance, the 
coagulum is found to be firmer and more circumscribed ; later 
still, it becomes white or yellow, and is surrounded by a brown- 
ish red fluid. The walls of the containing cavity are smooth, 
and lined with a delicate membrane. The surrounding cerebral 
substance in some cases retains its natural appearance, and in 
others is altered both in colour and consistence, becoming rose- 
coloured, red, brown, or yellow, and at the same time softer 
or more firm than usual. 

As the interval between the effusion and the examination 
increases, the coagula gradually disappear, and in their place 
we find either a small cavity lined with a yellowish membrane 
like a serous membrane, and containing a serous or gelatinous 
fluid; or a similar cavity containing a set of filaments parallel 
or intersecting, so as to form a kind of network not unlike cel- 
lular tissue, infiltrated with serum; or, lastly, a straight or puck- 
ered cicatrice produced by the approximation and adhesion of 
the parietes of the cavity : as to the time required for the for- 
mation of this cicatrice, we cannot fix any certain rule. It has 
been stated that it takes a much longer time to form when the 
effusion has occurred transversely to the cerebral fibres, than 
when it has occurred in a parallel line to them. 

I have now described the most usual mode of termination 
of cerebral haemorrhage in those cases where the patient re- 
covers; but I have reason to think that in some instances the 
coagulum, instead of being absorbed, may become organized, 
and thus form a sort of accidental tissue nourished by the arte- 
ries of the surrounding cerebral substance. The following 



* Dictionnaire de Medicine, par MM. Adelon, Andral, Beclard, &c. article 
Jlpoplexie. t Ibid. 



454 DISEASES OP THE BRAIN 

case, at least, appears strongly confirmative of such an opinion. 
In a man who died at La Charite, after having been for several 
years in a state of hemiplegia, resulting from an attack of apo- 
plexy, I found in one of the cerebral hemispheres a mass of a 
pale red colour, and fibrinous appearance, which was traversed 
by small vessels anastomosing with those of the brain : the sur- 
rounding portion of the nervous substance was natural, and the 
mass was not encysted. 

Anatomists had long remarked that the nervous pulp is very 
often softened around apoplectic effusions ; and used to attrib- 
ute this to the effusion, considering it as merely a secondary 
lesion : but M. Lallemand has clearly proved that the ramol- 
lissement, far from being always subsequent to the effusion, 
often precedes it, and is one of its causes. In fact, it is possi- 
ble to follow in a softened portion of the brain all the degrees 
between simple injection and sanguineous effusion. When the 
ramollissement does occur subsequently to the effusion, it is not 
the mechanical result of the maceration of the part by the 
blood, except in some few cases where the haemorrhage is very 
considerable ; but is rather produced by a process of irritation 
like that set up around every foreign body. As the effusion be- 
comes absorbed, and the cavity that contained it advances to- 
wards cicatrization, the surrounding nervous substance ceases 
to be injected, and regains its former consistence ; sometimes, 
indeed, it even acquires an unusual degree of hardness. 

In a great many cases of haemorrhage in the brain or spinal 
cord, there is no trace of alteration discoverable in the vessels 
of the part ; so that the haemorrhage must have arisen from ex- 
udation, or from the rupture of the capillaries. It often hap- 
pens, too, that, though we cannot discover, any more than in 
the preceding cases, the ruptured vessel from which the haem- 
orrhage proceeded, we yet find the whole of the circulatory sys- 
tem of the encephalon in an unnatural condition, most of the 
arteries being transformed into osseous canals, whose parietes, 
being incrusted with phosphate of lime, have lost their elasticity, 
and may be broken with the greatest ease by a slight pull, or 
by moderate distention. This state of the cerebral arteries is 



AND SPINAL CORD. 455 

very common in old people, and we know that they are most 
subject to apoplexy. 

Lastly, in a few cases, the vessel from which the hsemorrhage 
took place has been discovered, situated either on the walls of 
the cavity formed by the effused blood, or at some distance 
from that cavity. As to the effusions that take place on the 
external surface of the nervous centres, some proceed also from 
the capillaries, and others are owing to the rupture of some of 
the large vessels on the exterior of the brain or spinal cord. 
Thus, M. Serres* saw an attack of apoplexy result from the 
perforation of the basilar artery, which presented, near its su- 
perior bifurcation, an aneurismal sac large enough to contain 
a hen egg. In another fatal case of apoplexy observed by the 
same author, the effusion was produced by the perforation of 
the anterior communicating artery of the brain. 

It has been asserted that hypertrophy of the heart is frequent- 
ly observed in apoplectic patients, and that it is one of the causes 
of the haemorrhage. For my own part, I have observed this 
coincidence sufficiently often to have reason to believe the truth 
of the assertion. We know, too, that some of the effects of 
cerebral congestion, such as flushing of the face, giddiness, &c. 
are generally enumerated among the symptoms of hypertrophy 
of the heart. However, it appears from the researches of 
M. Rostan that affections of the heart are by no means so fre- 
quent in persons that die of apoplexy, so far as his own ex- 
perience goes; and M. Rochoux found only three cases of 
aneurism of the heart among forty-two apoplectic- individuals 
whose bodies he examined. I am inclined to think that we 
ought not to adopt the conclusion of M. Rochoux without ex- 
amining more minutely into the state of the case. At the 
period at which he made his researches, the term aneurism of 
the heart was applied only to those lesions of that organ in 
which its volume was increased. Now, this is not the lesion 
of the heart that occurs most frequently in apoplectic persons ; 



* Archives de Medecine, Vol. x. p. 419. 



456 DISEASES OP THE 

it is that species of hypertrophy of the organ in which the thick- 
ness of its parietes is increased at the expense of its cavity, 
while the bulk of the heart itself remains unaltered. Therefore, 
unless M. Rochoux assures us that he comprehended this kind 
of hypertrophy under the term aneurism of the heart, his re- 
searches on the subject cannot be depended on. 



ARTICLE II. 



Anemia of the nervous centres is produced under the in- 
fluence of the same causes as have been already assigned to 
anaemia in general. The affection may be confined to the 
brain, or may extend over the whole body. It is observed 
both in chronic and in certain acute diseases, in which, though 
the symptoms seemed to announce a state of irritation of the 
brain, that organ is found remarkably pale. As I have already 
insisted upon this topic, it is sufficient at present to remind the 
reader of the fact. However, I cannot help citing the follow- 
ing remarkable case, as an instance of how the depriving the 
brain of its accustomed stimuli may produce precisely the 
same effects as would arise from increasing them. 

A man greatly addicted to drunkenness was thrown into 
prison for robbery, and obliged to live upon bread and water. 
He had not long continued this new course of life when his in- 
tellects were observed to be disturbed, and he became pale, 
weak, and emaciated, and unable to sleep at night. Delirium 
at last supervened, at first gentle, but afterwards perfectly 
frantic. The medical attendant, having been informed of his 
previous habits of life, suspected that the symptoms were owing 
to the sudden and total abstinence from spirituous liquors ; and 



AND SPINAL CORD. 457 

consequently ordered him a small quantity of brandy twice a 
day. Under this treatment the cerebral symptoms soon dis- 
appeared, the patient gradually recovered his flesh and his 
strength, and was evidently restored to his former health, which 
he maintained during the remainder of his imprisonment. 



CHAPTER II. 



Lesions of Nutrition. 



The nutrition of the nervous centres varies greatly according 
to the nature, and still more, according to the age of each in- 
dividual ; and hence arise modifications in their form, bulk, and 
consistence, with which it is necessary to be well acquainted, 
in order not to refer them to disease. 

The cerebral hemispheres are by no means constantly sym- 
metrical, their corresponding convolutions being often dissimilar 
both in size and form. This does not produce any appreciable 
functional derangement. 

Every one knows that the size of the brain varies according 
to the individual. Considered in the same person at different 
ages, it continues to increase in size from birth up to manhood, 
and then remains stationary till old age, when it generally be- 
comes somewhat diminished both in bulk and specific gravity. 
The same may be said of the spinal cord.* 

The convolutions of the cerebral hemispheres are but little 
developed till towards the end of the first year after birth: in 
old age they begin to decrease anew both in length and thick- 



*Cazauvieilh, op. cit, Anatomic des systemei nerveux des animaux a vertebres, 
par Desmoulins, vol. u, p. 620. Ollivier, Traiti de la moelle ipinxert, vol. II, p. 720. 

Vol. II. 59 



458 DISEASES OF THE BRAIN 

ness. They vary greatly in different individuals in both par- 
ticulars, as also in number. It is to be observed, too that the 
largest brains have not always the most strongly marked con- 
volutions. 

The thalami optici, corpora striata, corpus collosum, and 
mesocephalon, all decrease in length in old age; the diameter 
of the cerebellum remains unaltered. 

It appears from the researches of M. Desmoulins that the 
bulk and specific gravity of the nervous centres undergoes no 
diminution in chronic diseases, however great the degree of 
general marasmus may be. Accordingly, in chronic diseases 
attended with considerable emaciation, a period arrives when 
the mass of the nervous system becomes too great in propor- 
tion to that of the others ; and hence, perhaps, arises that state 
of inordinate nervous excitability so common at a certain stage 
of those diseases. 

Having thus considered the natural variations of the nutrition 
of the nervous centres, let us now proceed to the lesions of 
that function that are to be observed in them. 



ARTICLE I. 



HYPERTROPHY OF THE NERVOUS CENTRES. 



We must take care not to confound this with the apparent 
enlargement produced whenever there is any considerable de- 
gree of hyperaemia of the part, as that depends on the in- 
creased quantity of blood, and not on a real increase of the 
nervous substance itself. 



AND SPINAL CORD. 459 

Hypertrophy of the brain appears to have been known by 
Morgagni, and has also been described by Laennec,* who men- 
tions his having found it in different subjects whom he had 
previously supposed to be affected with hydrocephalus internus. 
It has occasionally been found, too, in epileptic children, and 
in others that had died in convulsions. 

The anatomical characters of this affection are the follow- 
ing:! tne convolutions of the brain are crowded together and 
flattened, the intervals, betweeen them disappear, and it seems 
as if the immediate investing membranes of the brain had be- 
come too tight for it. The substance of the organ is firm, con- 
tains but little blood, and appears remarkably dry when cut 
into. The ventricles are, as it were, effaced, and the various 
surfaces of the brain deprived of their ordinary moisture. In 
other respects its texture remains unaltered. The affection 
generally involves both hemispheres, but is sometimes partial: 
thus, I saw a case where the left thalamus opticus was one- 
fourth larger than the right, which was of the natural size. 
There had not been any particular symptom observed during 
life that could lead to a suspicion of such a state of the parts. 

No instance of hypertrophy of the cerebellum has hitherto 
been published, but the spinal cord has occasionally been ob- 
served in a state of hypertrophy, as well throughout its whole 
extent, as in some one part only. The affection is announced 
by the enlargement and increased firmness of the cord, with- 
out the presence of hyperemia. The cord then fills the whole 
cavitv of the dura mater, and is closely applied to the parietes 
of the vertebral canal. Laennec observed this hypertrophy 
throughout the whole extent of the cord. Dr. Hutin mentions 
a case in which it existed from the occipital foramen to the 
middle of the dorsal region ; and I found it myself in the cer- 
vical region in a child that was subject to epilepsy. 

I must give the same caution with respect to the spinal cord 
as I did with respect to the brain, namely, to take care not to 



* Journal de Corvisart, SfC. vol. H. 669. 
t Repertoire d' Anatomie, fyc. vol. v. 



460 DISEASES OF THE BItAIN 

confound its enlargement from hyperemia with that arising 
from hypertrophy. Perhaps I ought to refer to hypertrophy 
some cases mentioned by M, Ollivier, in which the cord pre- 
sented an evident bulbous swelling immediately above the 
point where it had been subject to strong compression. 

Hypertrophy of the nervous centres often exists without any 
appreciable enlargement of their osseous envelope. In some 
cases, however, the enlargement of the brain is carried to such 
an extent, that the skull also becomes enlarged. In a case of 
this description recorded in the seventh volume of the Archives 
de Medecine, the subject, a child of five years of age, had a head 
as large as that of a stout man ; and the parietes of the crani- 
um varied from a line and a half to two lines in thickness. It 
was chiefly the hemispheres that were enlarged. There had 
not been any peculiarity observed in its intellectual faculties ; 
and its death was owing, not to the cerebral affection, but to an 
accidental attack of gastro-intestinal irritation. 

In studying the alterations of other organs, we have often 
met with cases in which the proper tissue of the organ was in a 
state of hypertrophy: similar cases have been observed in the 
nervous centres. I once found one of the thalami optici and 
the neighbouring parts transformed into a cellulo-vascular sub- 
stance not unlike the tissue of the spleen, in which there was no 
trace of nervous substance to be discovered. The case pub- 
lished in the Philosophical Transactions of the Royal Society 
of London, for the year 1825, under the title of Fungus hazmat- 
odes of the Brain, appears to me to have been much of the 
same description ; for it is stated in it that the thalami optici 
were converted into a fungous tissue, and that, internally, they 
resembled a mass of coagulated blood, like that found in the 
spleen. In like manner, the case mentioned in Magendie's 
Journal de Physiologie, relative to a fungous mass found on 
part of the anterior face of the spinal cord of a woman, is, in 
my opinion, to be referred to hypertrophy of the cellulo-vascu- 
lar tissue of the part. 



AND SPINAL CORD. 461 



ARTICLE II. 



ATROPHY OP THE NERVOUS CENTRES. 



Of this there are several degrees, from a slight diminution 
of the nervous centres, either throughout, or in some of their 
parts, to the total absence of those centres.* 

Atrophy does not occur with equal frequency in all parts of 
the cerebro-spinal axis : we may lay it down as a general rule 
that it is most frequently observed in those parts which are the 
last to attain their perfect developement. Thus, the spinal 
cord is formed before the brain, and atrophy of the former is 
much more uncommon than that of the latter. Again, the con- 
volutions of the brain, which are the last parts developed, are 
the most frequently found in a state of atrophy. 

Let us now proceed to consider the various degrees of this 
affection, as well as the parts where it has been chiefly ob- 
served. 

The cerebral hemispheres have been more frequently found 
in a state of atrophy than any other part of the nervous centres ; 
and the affection may be either partial, or general. Partial 
atrophy of the hemispheres may affect : — 

1. The convolutions. In some cases these are only smaller 
and less numerous than usual, either on both sides, on one side 
only, or in some parts of one side ; in others, they are totally 
absent, as was observed in the brain of an idiot, of between 
five and six years of age, presented by M. Jadelot to the 
Acadamie Royale de Medecine. 

2. The whole superior part, from the external surface to the 
roof of the ventricles, which of course then lie immediately 



* Vide Archives de Medecine, vol. xiv. 



462 DISEASES OF THE BRAIN 

under the meninges ; except when, as sometimes happens, we 
find in its place a serous sac, which has no communication with 
the ventricles. Sometimes the atrophy is not considerable, and 
we merely find one hemisphere smaller than the other, or even 
one lobe, only, either smaller or altogether absent. 

The thalami optici, and the corpora striata. The atrophy 
sometimes affects particularly the grey substance of these parts, 
and sometimes the white ; which may produce a difference in 
the symptoms observed. Instead of being merely diminished, 
these parts may be completely absent, and be then replaced or 
not by a serous cyst. 

4. The white central parts of the brain. These may be im- 
perfectly developed in cases where there is no alteration in the 
hemispheres. Reil found the corpus callosum completely de- 
ficient in an idiotic female of the age of thirty. The cerebral 
hemispheres communicated only by the anterior and posterior 
commissures. 

It is a remarkable fact, that when the cerebral lobes are ab- 
sent, we sometimes find in the anterior part of the cranium 
two small masses of nervous substance, from whence the ol- 
factory nerves arise. These are evidently the olfactory lobes, 
which thus display in man, in the morbid state, that independ- 
ent existence which, in animals, is evident in the natural state. 

One or both of the lateral lobes of the cerebellum have been 
occasionally found in a state of atrophy. M. Hutin mentions 
a case in which the medullary centre of the cerebellum was 
about one-third smaller than usual. 

The hemispheres of the cerebellum, instead of being simply 
diminished, may present nothing but a cavity whose walls con- 
sist of a delicate lamina attached to the corpora restiformia, 
of which it appears to be an expansion. In such cases, the 
median lobe of the cerebellum, (inferior vermiform process,) 
and the tuber annulare, are also deficient, leaving the crura 
cerebri exposed to view. The tubercula quadrigemina may 
be present, even when the cerebellum is almost totally de- 
ficient. 

The pineal gland is occasionally so diminished as almost to 
vanish. It was once found in an idiot transformed into a small 



AND SPINAL CORD. 463 

granule scarcely the size of a grain of millet. Its variations in 
bulk do not necessarily involve any derangement in the nutri- 
tion of the other parts of the brain. 

We have now seen that the various masses of nervous mat- 
ter may diminish or even disappear altogether, leaving nothing 
but the medulla oblongata. Let us next turn our attention to 
the vertebral canal, and we shall find that the spinal cord may 
exist whether the brain be present or not, but that no part of the 
latter is ever found in the absence of the former. Thus, pa- 
thological anatomy concurs with comparative anatomy and 
embryology in proving the dependence of the developement 
of the brain on that of the spinal cord. 

We have many cases to prove that the spinal cord may 'be 
completely absent : when that happens, the cavities usually oc- 
cupied by the nervous centres contain a fluid, and their walls 
consist of membranes resembling the meninges, in which the 
nerves terminate. It may also present various malformations, 
of which some resemble the different stages through which it 
passes in its progress to the perfect state, and all depend on an 
arrest or retrogradation of developement. 

Thus, the two cords of which it is composed at an early pe- 
riod of its formation may remain separate on account of the 
non-deposition of the grey substance in the intervening space : 
this malformation is always accompanied by anencephalia. 
When these two cords do unite, they form a channel, and, sub- 
sequently, a canal, which continues permanent in many ani- 
mals, but in the human subject is generally obliterated at the 
period of birth. It may, however, persist, and we then find a 
cavity in the centre of the medulla spinalis, the existence of 
which seems connected with the absence of the central grey 
substance. In some cases it is accompanied by other malform- 
ations, such as anencephalia, or spina bifida ; in others, not. 
It always commences at the superior extremity of the spinal 
cord, where it appears to form a continuation of the fourth 
ventricle ; and may extend as far as the commencement or 
middle of the dorsal region, but not much lower. It is some- 
times barely large enough to admit a fine probe, while in other 



464 DISEASES OF THE BRAIN 

cases a goose quill could readily be introduced into it. It has 
been found in subjects of all ages. 

It has been asserted by some anatomists, that, besides the 
central canal, there are naturally two lateral ones in the spinal 
cord ; this, however, is not the case, but they are sometimes 
found as a morbid condition either reaching through the whole 
extent of the cord, or only as far as the cervical portion. 

Another kind of atrophy of the spinal cord is where it is di- 
minished in size. This may be either general or partial. M. 01- 
livier saw two cases of atrophy of the cord throughout its whole 
extent ; in one it was reduced to half, and in another to two- 
thirds of its natural bulk. Magendie mentions another, where 
it was accompanied by induration. 

The cranium generally indicates, by its malformation, the 
various degrees of atrophy of the brain. However, I once 
saw a case where in the place of the upper part of the cerebral 
hemispheres there was a sac full of serous fluid, and yet the 
cranium was perfectly well formed. Similar cases have been 
observed by others.* 

The nerves terminating in the atrophied parts of the cerebro- 
spinal axis do not always present the same appearance. Those 
of the spinal cord are sometimes as large as usual, and may even 
be found attached to its membranes in cases of its total ab- 
sence; sometimes, on the contrary, they partake in its atrophy, 
either at their origin only, or throughout their whole extent. 

In cases of partial atrophy, the parts of the body that receive 
nervous influence from the affected portions of the brain are 
themselves often in a state of atrophy. Thus, in almost all 
cases of atrophy of one of the cerebral hemispheres, the mem- 
bers of the opposite side are found less developed than ordina- 
ry ; this, however, may result from the complete state of repose 
in which they remain. 

Atrophy of the nervous centres cannot be referred to the 
influence of any single cause in particular. 



* Diclionnaire de Medecine, art. Hydrocephalic. 



AND SPINAL CORD. 465 

1. It may occur without any known cause, either before or 
after their perfect developement. 

2. It may occur subsequently to a process of irritation in the 
part. Thus, in persons who at a distant period before death 
had presented all the symptoms of cerebral haemorrhage, it is 
not uncommon to find some part of the brain, particularly the 
corpora striata or thalami optici, singularly diminished in size, 
and transformed into a kind of serous cavity. 

3. It may be produced by mechanical compression. Thus, 
tumours in the interior of the cranium, have sometimes caused 
the disappearance, or at least a considerable diminution, of the 
convolutions with which they happened to be in contact; and 
one of the effects of caries of the vertebrae is to cause the "atro- 
phy of the portion of spinal cord compressed by the displaced 
vertebrae. 

4. Lastly, the want of exercise of the functions of the ner- 
vous centres may produce in them a diminution of nutrition, 
and thus prove a cause of atrophy. We know that when a 
muscle is not exercised, it wastes away in like manner. Hence 
it follows that the atrophy of the brain generally observed in 
idiots, instead of being the cause of their disorder, may perhaps 
be only an effect of it. 



ARTICLE III. 

* RAMOLLISSEMENT OP THE NERVOUS CENTRES. 

Tins name is applied to a peculiar morbid state of the ner- 
vous centres, in which they present an evident diminution of 



* I have been induced to use this word instead of softening, as I perceive it has 
been adopted by most English authors, though I cannot but think our own term 
equally expressive. T. 

Vol II. 60 



466 DISEASES OF THE BRAIN 

consistence, which is sometimes carried so far as to amount 
almost or altogether to liquefaction. Of course, the naturally 
soft state of the brain at birth does not come under this denom- 
ination ; nor yet the diminished consistence of that organ that is 
usually observed in persons who die of chronic disease. We 
must recollect, too, that all the parts of cerebro-spinal axis are 
not naturally of the same degree of consistence ; and that the 
interval elapsed after death, and the manner of opening the 
head or vertebral canal, may produce alterations in that con- 
sistence which would mislead us if we were not on our guard 
against those various sources of error. 

Ramollissement of the nervous centres presents several de- 
grees. In the first, the change of consistence is perceptible 
only to the touch. In the second, the nervous substance is so 
diffluent that the change is perceptible to the eye. In the 
third, it is completely fluid, its texture being totally destroyed, 
and nothing appearing in its place but a kind of cellular struc- 
ture which appears to be the original framework of the part. 
Lastly, in the fourth degree, even this trace of structure disap- 
pears, and there is a complete solution of continuity. 

The affected nervous substance may either preserve its natu- 
ral colour, assume a new one, or be totally deprived of all col- 
our whatever. 

The natural colour is preserved chiefly in those cases where 
the ramollissement is situated in the medullary substance. The 
preternatural colours assumed are principally the following, of 
which there are numberless shades running into one another: 
rose red, purple, brown, violet, yellow, greenish yellow, light 
grey, and deep grey. 

The softened parts occasionally contain effused blood, or 
pus, either infiltrating them or collected into a body. M. Lal- 
lemand imagines that in every case of white ramollissement, 
the white colour results from purulent infiltration. I cannot 
agree with him in this, for, in many cases of the kind there is 
nothing like pus to be seen. Sometimes, also, the softened 
portion has a smell of sulphuretted hydrogen. 

There is no one part of the nervous centres in which ramol- 
lissement has not been observed : however, the parts where it 



AND SPINAL CORD. 467 

is most frequently found are also those in which haemorrhage is 
most common, namely, the thalami optici, corpora striata, and 
the surrounding parts. It occurs much more frequently in the 
grey substance than in the white. 

In the cerebral hemispheres, the ramollissement may af- 
fect: — 

1. The cortical substance of the convolutions, the white sub- 
stance beneath remaining untouched. This partial ramollisse- 
ment deserves the more attention, as it readily escapes dis- 
covery when one is not previously aware of the possibility of 
its existence. It frequently accompanies active hyperamia of 
the meninges. 

2. A more or less extensive portion of the mass situated 
above the lateral ventricles. The affection sometimes occurs 
only in a few small isolated points, and yet the symptoms 
may be as severe as if the whole lobe were softened. When 
the ramollissement takes place near the surface of the hemi- 
sphere, its convolutions often become shapeless and flattened, 
and sometimes even present a kind of fluctuation. 

3. The parietes of the lateral ventricles. I have sometimes 
found a softened and diffluent layer of nervous substance ex- 
tended over these parietes, while the cavity contained a turbid 
fluid. 

4. The thalami optici. In these, the affection sometimes 
attacks exclusively their external white layer, and sometimes 
their internal grey substance. 

5. The corpora striata. 

6. The parts on a level with, and external to, the two pre- 
ceding. 

7. The cornu Ammonia and Hippocampus minor. 

8. The corpus callosum, fornix, and septum lucidum. 
Softening of the other parts of the cerebro-spinal axis is less 

frequent than that of the brain properly so called. However, 
it has been observed in the mesocephalon, in the various por- 
tions of the cerebellum, and in the spinal cord. 

The spinal cord has been sometimes found softened through- 
out its whole extent; but in general it is only so in some one 
part. Moreover, the two substances that enter into its compo- 



468 DISEASES OF THE BRAIN 

sition may eacli be softened separately. When it is the in- 
ternal grey substance that is affected with ramollissement, its 
liquefaction may produce accidental canals in the interior of 
the cord, which of course occupy the situation and present the 
form of that substance. M. Reynaud and I dissected two 
spinal cords that had such canals. 

Ramollissement of the nervous centres may exist in one 
single point, or in several points at once. When in the hemi- 
spheres, it may affect corressponding parts in each; and, lastly, 
it may occur simultaneously or successively in the brain proper- 
ly so called, and in the other parts of the cerebrospinal axis. 
General ramollissement is exceedingly rare in adults, but oc- 
curs sometimes in new-born infants. In thirty cases of pulta- 
ceous ramollissement of the brain observed by M. Billard, there 
were ten in which the affection extended to the whole of the 
spinal cord also ; and in each of those ten cases the odour of 
sulphuretted hydrogen was perceptible. The infants in whom 
this alteration was observed lived for some days after birth, but 
their respiration was laborious and imperfect, their limbs were 
flaccid and motionless, and the pulsations of the heart scarcely 
perceptible. 

Ramollissement of the nervous centres occurs at all ages, 
but is most frequent in old people, and next to them, in adults. 
Between fifteen and twenty it is rather uncommon, but be- 
comes less so between two and fifteen years of age. Lastly, 
it appears from the labours of M. Billard that it may occur 
immediately after birth, and it is then more considerable and 
more extensive than at any other period of life. Indeed, it is 
probable that in some cases it begins even before birth. 

What is the nature, and what are the causes of this affection? 
According to M. Lallemand, in his celebrated work on the sub- 
ject, it is the constant and necessary result of an acute or 
chronic irritation of the parts ; and he has skilfully pointed out 
the various degrees of this irritation, from simple injection, to 
ramollissement, and purulent infiltration, and lastly, to the for- 
mation of collections of pus. But, this theory is not applicable 
to every case ; and I am inclined to agree with M. Rostan that 
there are many which have nothing at all to do with irritation. 



AND SPINAL CORD. 469 

We often meet with cases where there is no appearance of 
sanguineous congestion, nor yet of purulent infiltration, or of 
any morbid secretion, a simple diminution of consistence being 
all that is to be seen. Neither can we demonstrate the neces- 
sary previous existence of irritation by the nature of the symp- 
toms ; for we have often found that identity of functional de- 
rangements is no proof of the identity of the lesions that pro- 
duce them. In fact, in the present state of our knowledge on 
the subject, it would be almost impossible, without having re- 
course to mere hypothesis, to assign the cause of ramollisse- 
ment of the nervous centres in those cases in which it does not 
seem to have been preceded by irritation. The opinion of 
M. Rostan, that it is something of the same nature with gan- 
grena senilis, is merely conjectural, though it might be support- 
ed, at least, as well as the other. 



ARTICLE IV. 



INDURATION OP THE NERVOUS CENTRES. 



The consistence of the nervous centres is sometimes remark- 
ably increased, either throughout their whole extent, or only 
in some particular parts. 

There are various degrees of this increase of consistence. 
In the first degree, the affected part presents the consistence 
of a brain that has been kept for some time immersed in diluted 
nitric acid ; in the second, it is as firm as wax ; and in the 
third, it is as firm and elastic as fibro-cartilage. 

In the first degree, the nervous substance may contain little 
or no blood, and is of a remarkable silvery whiteness. 

I have already said that the induration may be either gene- 
ral or partial. When general, it has never been observed to 



470 DISEASES OP THE BRAIN 

exceed the first degree. The whole brain is then remarkably 
firm, but not equally so throughout, the white substance being 
in general harder than the grey, especially in the central parts 
of the brain, as well as at the origin of the various nerves. In 
some cases the hyperemia shows itself only in some points of 
the brain, while the parts in which it does not appear are, not- 
withstanding, almost equally firm. 

General induration of the brain has been principally observed 
in persons that had presented all the symptoms of ataxic fever. 
I also found it in two individuals who had been in the habit of 
handling lead, and who died in a state of general convulsion. 

The spinal cord may also become indurated throughout its 
whole extent. M. Billard once found this carried to such a 
degree in a new-born infant, that the cord, after being stripped 
of its membranes, was able to support nearly a pound weight : 
the infant had had convulsions in its limbs, and the meninges 
were lined with thick false membranes. Induration of the spi- 
nal cord, like that of the brain, affects principally the white 
substance, the grey being generally exempt from it. 

Partial induration of the nervous centres is most frequently 
found in the second and third degrees, and is, moreover, a 
chronic affection, whereas general induration seems to be most 
frequently an acute one. It has been observed in various 
parts of the nervous centres, and, among the rest, in the cere- 
bral convolutions. When the affection is at all considerable, 
the grey substance disappears, or at least is scarcely to be dis- 
tinguished from the white. However^ in a case mentioned by 
M. Lallemand, the induration existed solely in the cortical sub- 
stance of a few of the convolutions, and the white substance 
beneath was softened. 

Induration of the centre of the medullary substance of the 
cerebral hemispheres was observed by M. Pinel in a woman 
who died in a state of insanity ; the posterior and inferior mar- 
gin of the cerebellum was also so indurated as to become al- 
most fibro-cartilaginous. M. Payen once found, in a girl six 
years old, a depression in the posterior third of the left cere- 
bral hemisphere, which was owing to the induration and shrink- 
ing of one of the convolutions. The superjacent membranes 



AND SPINAL CORD. 471 

were thickened and white, and accurately defined the extent 
of the diseased part. The girl, who was of a melancholy tem- 
perament, but remarkably intelligent, had had from her birth 
a contraction of the right wrist and foot, together with slight 
atrophy and incomplete hemiplegia of the same side. 

Partial induration often accompanies other alterations of the 
nervous centres : thus, the portions of nervous substance that 
form the walls of accidental cavities containing old effusions 
of blood, or certain morbid productions, are often found in- 
durated. 

The causes of induration of the nervous centres are still 
rather obscure. However, when we consider that general in- 
duration in the first degree, as well of the brain as of the spinal 
cord, is usually accompanied during life by all the symptoms 
that characterize irritation of the nervous centres, and that, be- 
sides, we often find, after death, traces of irritation of the menin- 
ges, and injection of the nervous substance itself, we shall find 
reason to conclude that this kind of induration results from irri- 
tation, or, if you will, from a degree of encephalitis. 

As to partial induration, it may in some cases be, like the 
former, the result of irritation ; of which its existing around 
old effusions and several morbid productions, together with 
the thickened and infiltrated condition of the meninges near 
the indurated parts, may be adduced as proofs. But still, we 
must bear in mind that, in the greater number of the cases of 
partial induration hitherto observed, the antecedent existence 
of induration is merely hypothetical ; so that we must wait for 
farther information before we can venture to decide positively 
on the subject. M. Lallemand has suggested that, in some 
cases, partial induration of the brain ought to be considered as 
a mode of recovery from ramollissement ; but this also requires 
confirmation. 



472 DISEASES OF THE BRAIN 



ARTICLE V. 



ULCERATION OF THE NERVOUS CENTRES. 



I do not mean to speak here of the consecutive ulceration, 
that occurs after cerebral haemorrhage, ramollissement, &c. ; 
but of that which is unaccompanied by any other alteration. 
We occasionally find, either on the external surface of the 
cerebral hemispheres, or on that of the corpora striata and 
thalami optici, some points in which the nervous substance is 
superficially eroded, so as to form ulcers of various sizes and 
forms. We must be on our guard against mistaking for these 
ulcers the solutions of continuity that are sometimes so readily 
produced in the cortical substance of the convolutions, when in 
a state of ramollissement, by detaching the pia mater. ' 

There are some interesting cases of ulceration of the brain 
recorded in the seventh volume of the Archives de Medecine. 
One of them is relative to a soldier twenty-four years of age, 
who died with all the symptoms of irritation of the alimentary 
canal and of the brain. At the commencement of his disease, 
he had been attacked with an exceedingly severe pain about 
the orbits, which continued to the last, and used to cause him 
frequently to scream with agony. On opening the body, there 
was found on the inferior part of the anterior lobe of one of the 
cerebral hemispheres an ulcer thirteen lines in length and seven 
in breadth, and of a yellowish appearance ; its surface was 
hard and dry, and its edges were uneven and ragged. The 
subjacent cerebral substance was sound, as was also the rest of 
the brain ; but the arachnoid was strongly injected throughout, 
and the part of it corresponding to the ulcer was destroyed. 
In another case, there had not been any pain in the head, and 
the death of the patient was caused by a gastro-intestinal irrita- 



AND SriNAL CORD. . 473 

tion, which at the latter end of the disease produced delirium. 
There were two small ulcers found on one of the posterior 
lobes of the brain, involving only the grey substance. The 
surrounding portion of the brain was injected. 



CHAPTER III. 



Lesions of Secretion. 



The morbid secretions found in the nervous centres occur in 
three different forms : — 

1. In intimate combination with the nervous tissue. 

2. Contained in an accidental cavity whose parietes are 
formed by the nervous substance itself, the surrounding por- 
tion at the same time generally presenting different alterations. 

3. Contained in an accidental cavity whose parietes are con- 
stituted by one or more accidental membranes, the surround- 
ing nervous substance being at the same time in general sound. 

The accidental membranes that form the parietes of the 
cysts in the third form are of various kinds. The tissues of 
which they are composed are the vascular, the cellular, the se- 
rous, a cellulo-vascular tissue which generally resembles mu- 
cous tissue, the fibrous, the cartilaginous and the osseous. 
These may exist either single or combined in the one cyst, and 
the period at which this cyst is completely formed is often also 
the period at which the morbid productions cease to announce 
their presence by any particular symptoms ; which evidently 
arises from the circumstance that the previously diseased sur- 
rounding nervous substance then becomes healthy again. 
Hence it follows, that the severity and nature of the symptoms 
produced by the developement of any morbid production in 
Vol. II. 61 



474 • DISEASES OP THE BRAIN 

the nervous centres, depend less on the mere existence of that 
production, than on the condition of the surrounding nervous 
substance. 



ARTICLE I. 



EXHALATION OF SERUM IN OR AROUND THE NERVOUS CENTRES. 



I have already repeatedly had occasion to allude to the in- 
genious researches of M. Magendie with respect to the cere- 
bro-spinal fluid. An acquaintance with the nature and seat of 
this fluid, and with its variations as to quantity, quality, and sit- 
uation, may lead us to the discovery of so many important pa- 
thological facts, that I consider it indispensably necessary to 
give some account of it. Before Magendie had directed the 
attention of physiologists to the existence of this fluid, and had 
determined its functions, who would have thought that the most 
serious consequences may result merely from an increase or 
diminution in its quantity ? Such, however, is actually the 
case. Its removal immediately produces in an animal a sin- 
gular state of dulness and stupor, from which it does not re- 
cover until a fresh supply has been secreted, which is not till 
after some days : the older the animal the more marked the 
symptoms. In one case, however, the same operation pro- 
duced in the animal a kind of maniacal fury, which resembled 
madness, but certainly was not hydrophobia. The artificial 
accumulation of this fluid in the vertebral canal sometimes 
causes paralysis. 

In the human subject, the cerebro-spinal fluid usually amounts 
to about two ounces. It is probable that its diminution pro- 
duces a great many nervous affections which could not before 
this be accounted for by the discovery of any appreciable lesion 



AND SPINAL CORD. 475 

in ther nervous centres, or else were referred to alterations 
that were not their true cause. Its increase is the cause of 
certain cases of serous effusion in the substance or in the ven- 
tricles of the nervous centres; for M. Magendie has ascertained 
the existence of a natural communication between the suba- 
rachnoid spinal cavity, where the fluid in question is principally- 
situated, and the fourth ventricle, from which it readily passes 
into the other ventricles. This communication exists opposite 
the end of the fourth ventricle, at the part known by the name 
of the calamus scriptorius : the apperture which forms it is cir- 
cular, and is two or three lines in diameter; it may be discov- 
ered between the two posterior arteries of the cerebellum. In 
several cases of serous effusion into the ventricles, M. Magendie 
found both this aperture and the fissura Sylvii perceptibly en- 
larged. He is of opinion that the quantity of the fluid cannot 
much exceed two ounces without producing some bad effects. 

Collections of serum may be formed either in the substance 
of the nervous centres, or in their investing membranes. In 
the former case, the serum may infiltrate the nervous substance, 
or may be contained in a cavity. M. Guersent has described a 
peculiar state of the brain in children, in which various parts of 
it are so much infiltrated with serum as to be quite softened. 
The affection is most frequently observed in the white central 
parts that connect the two cerebral hemispheres; but it also 
occurs occasionally in some of the neighbouring parts. In the 
greater number of cases of it observed by M. Guersent, there 
was also a considerable effusion of serum in the ventricles; 
however, it is sometimes found without any such effusion, 
which proves that it is not the mere mechanical result of the 
maceration of the cerebral substance by the effused fluid. I 
have often observed a similar state of oedema of the brain in 
adults, but have never found it attended by any particular 
symptom: M. Guersent makes the same remark with respect 
to its occurrence in children.* 

The serum that is found collected in accidental cavities 
formed in the nervous substance, is in general effused there 



* Dictionnaire de Medecine, torn. n. p. 310. 



476 DISEASES OF THE BRAIN 

subsequently to certain lesions already described, to an effu- 
sion of blood, for instance. A membrane becomes organized 
around the coagulum, and afterwards furnishes the serum. In 
other cases, we find a vast cyst filled with serum, supplying 
the place of an atrophied portion of the brain. 

The serum effused on the various surfaces of the nervous 
centres may be situated, 1. between the dura mater and the 
parietes of the cranium; 2. between the arachnoid and the 
dura mater; 3. in the great cavity of the arachnoid around the 
encephalon; 4. in the subarachnoid cellular tissue (pia mater); 
5. in the different ventricles, and even in the cavity between 
the two folds of the septum lucidum. M. Breschet has in more 
than one instance discovered a genuine dropsy of this fifth 
ventricle, in children from six to twelve months old.* 

The quantity of serum effused in these situations varies from 
a few drachms to several pints. It is never very considerable 
when the effusion is the result of an acute affection. As long 
as the effusion is not very copious, the cavities of the brain are 
much distended, and its substance, though it may be more or 
less compressed, remains entire. But, when it is so consider- 
able as to tend to fill of itself the whole of the cavity of the 
cranium, the cerebral substance first loses its form, and at last 
disappears. In some cases, the mass of the hemispheres is 
reduced to a delicate lamina, like that of which it consisted 
in the early period of foetal life. In others, there is not even a 
vestige of the part to be found, and the whole of the brain 
above the ventricles is transformed into a serous sac, the walls 
of which consist of the meninges. Lastly, in other cases, the 
destruction of the brain is still deeper; but these fall under the 
cases of anencephalia, of which I have already treated. 

While the serum thus tends to occupy the place of the ner- 
vous substance in the interior of the cranium, the latter gener- 
ally becomes enlarged : indeed every one must be familiar with 
the appearance of hydrocephalous patients. In some cases, 
however, the head retains its natural dimensions ; and in others, 



* Dictionnaire de Midecine, art. Hydrocephah chronique. 



AND SPINAL CORD. 477 

far from being enlarged, it evidently becomes smaller than 
natural. The bones of which the cranial parietes are composed 
are often found in the natural condition ; in other cases, they 
are exceedingly thin, and are separated from each other by 
large cartilaginous intervals; lastly, in others, they grow ex- 
cessively thick. We see, then, that there is no constant rela- 
tion, either with respect to form or to nutrition, between the 
state of the brain and that of its osseous envelope. 

That kind of effusion of serum that is not sufficiently copious 
to produce any deformity in the brain, may occur at any pe- 
riod of life, either as an acute or as a chronic disease. It often 
co-exists with different lesions of the brain or its membranes, 
that are perceptible in the dead body; and it may, in certain 
cases, be considered to arise from them. The lesions that 
generally precede or accompany it are, injection of the nervous 
substance or of its investing membranes, ramollissement, an 
old or recent apoplectic coagulum, or an accidental production 
developed in the cerebral parenchyma. Sometimes, however, 
we cannot find any thing in the brain or its appendages except 
a great quantity of limpid serum. We must take care not to 
mistake for the effect of disease the small quantity of serosity 
that is usually found accumulated in the cerebral ventricles. 

The effusion may take place in a few hours; and we have 
then the not very common disease known by the name of 
serous apoplexy. It generally, however, takes a few days to 
form : and we then observe that assemblage of symptoms that 
has been described by the name of acute hydrocephalus. It is 
as yet by no means well determined how far the effusion is 
concerned in the production of these symptoms; as it often ap- 
pears unattended by them, or, indeed, by any other cerebral 
symptoms, while, on the other hand, we as frequently observe 
those symptoms in cases where, after death, there is not any 
effusion worth mentioning to be found either in the ventricles 
or elsewhere. Some writers have of late described, under the 
name of chronic hydrocephalus of the old, a disease character- 
ized by the gradual weakness of the various cerebral functions, 
in which, as they assert, there is nothing to be found on exami- 
nation after death, but a considerable accumulation of serum 



478 DISEASES OF THE BRAIN 

either in the subarachnoid cellular tissue of the external sur- 
face of the brain, or in the ventricles. 

The effusion that is so copious as to deform or destroy the 
surface of the brain, is generally a congenital affection, though 
it has sometimes been known to occur after birth. Little is 
known as to the causes that give rise to it ; and though in some 
cases it has appeared to succeed an irritation of the brain or its 
membranes, we must allow that in most instances we are to- 
tally ignorant of its source. It leaves the question where it 
found it to say that there is, in such cases, a co-existence be- 
tween the arrest of developement of the brain, and an unu- 
sually copious exhalation from its investing membranes; for 
we are still in the dark as to which of the two lesions is the 
primary one. 

The accumulation of serous fluid in the membranes or in the 
substance of the spinal cord, has been denominated hydrora- 
chis* In this disease, the fluid is sometimes merely effused 
either in the arachnoid or between it and the pia mater; and 
sometimes occupies the place of the cord itself, which is then 
imperfectly developed. 

There are two kinds of hydrorachis, the accidental and the 
congenital, each of which comprises two varieties, according 
as the vertebrae are divided or not. Division of the vertebra? 
is most common in cases of congenital hydrorachis, but has also 
occasionally been observed in cases of accidental hydrorachis 
in adults ; it is well known by the name of spina bifida, and by 
some authors is termed tumor lumbaris, from its being generally 
situated in the lumbar region. The most fequent cause of this 
disease appears to be an arrest of developement of the osseous 
parietes of the vertebral canal, connected either with dropsy 
of the investing membranes of the spinal cord, or with an arrest 
of developement of the latter also, in consequence of which it 
remains in its original fluid state. In those rare cases where 
spina bifida has been observed in adults, we must suppose 



* This term is more correct than hydrorachitis, being composed of iS'uo aqua, 
and p*vi£ , spina, and being therefore analogous to hydrocephalus, hydrometra. 



AND SPINAL CORD. 479 

either a secondary alteration of nutrition in the vertebra, or a 
process of absorption whereby they are brought back to the 
primitive state of developement. 

Spina bifida is characterized externally by the presence of 
one or more tumours situated on the vertebral column. In the 
greater number of cases, they are situated on the lumbar ver- 
tebrae, but also occur pretty often in the sacrum, more rarely 
on the back, and more so still towards the neck. Their mag- 
nitude is very variable: some are scarcely as large as a nut; 
indeed, properly speaking, there is sometimes no tumour at all, 
but merely a slight projection of the skin, which is transparent, 
and conveys a sense of fluctuation; others, again, are as large 
as an infant's head ; while, in some cases, the tumour is more 
remarkable for its great extent, than for its bulk in any one 
point. For instance, when the spinal canal is open posteriorly 
through its whole extent, we observe the skin or other mem- 
branes forming a uniform or uneven projection along the mid- 
dle of the back. Their form is equally variable with their sit- 
uation and magnitude. Some are globular, others, elongated 
or oval; sometimes they are largest at their base, and some- 
times they are attached only by a narrow pedicle. The last 
case occurs chiefly when the opening in the vertebras is very 
small. When there are several tumours, by pressing on one, 
we generally increase the size of the others, which proves that 
they communicate freely. In general, too, the seat of the tu- 
mour being in the lumbar region, its bulk increases when the 
patient is in an upright position. 

The parietes of the tumour have not always the same ana- 
tomical composition. In some cases they are formed, proceed- 
ing from without inwards, 1. by the skin, which may be per- 
fectly sound, thickened, attenuated, ulcerated, almost gangren- 
ous, or covered with fungous growths or tufts of hair ; 2. by the 
membranes